Neonatal Policies and Procedures

Tuesday, November 3, 2009

Grace J. Dublanko
Quality, Safety and Risk Management, BC Women's Hospital & Health Centre, Vancouver, BC, Canada
Marilynn Kendall, MA, BSN, RN
Neonatal Program, BC Women's Hospital & Health Centre, Vancouver, BC, Canada

Learning Objective 1: The learner will be able to view survey results on policy usage before and after revision and consolidation.

Learning Objective 2: The learner will be able to augment knowledge of a change journey in leadership development responding to implementation of standardization, simplification and interdisciplinary practice assimilation.

Policies and procedures provide a resource for knowledge and practice in delivery of patient care. The current Neonatal Program Policy Manual lacked the components of an integrated manual. In a large tertiary neonatal program centre, an interdisciplinary project was undertaken to consolidate a comprehensive manual. Led by a quality advisor the goal of the project was two fold 1) revise policies according to an established framework and 2) approve policies per the administrative organizational chart. The goal of the project was to update and standardize the Program Policy and Procedure Manual by leading an interdisciplinary team to facilitate consistency, accessibility online, archival, incorporating a systematic structure, a recognized approval process and simplify information to provide an excellent and resourceful manual for staff.  The poster reports data on policy usage before revision and after consolidation.