Increasing Staff Members' Ability to Develop, Revise, and Access Department Policies and Procedures
Public Health Solutions District Health Department (PHS) was chosen as a beta test site for the Public Health Accreditation Board (PHAB) accreditation process. Through that process, overall strengths and weaknesses were identified. A major shortcoming across PHS was inadequate documentation of policies and procedures and inadequate documentation of decision making. The availability of a small amount of grant funds from the Nebraska Department of Health and Human Services (NDHHS) provided PHS with an opportunity to engage in a quality improvement (QI) project. Of the many areas in which such a project could be done, improvement of the policy and procedure process within PHS was selected because of its overall importance to successful operation and accreditation. Although no procedure is documented for the establishment of policies and procedures, PHS has followed a predictable sequence. The inherent problem is that PHS started operation without a basic policy framework. Consequently, many policies and procedures were prepared as needed. If there were time constraints, as was often the case, the procedures or policies were not adequately documented, secured, and placed in one location. This resulted in a patchwork of policies and procedures with many gaps. Further, these policies were not regularly reviewed and were not easily located. Therefore, some of PHS's operations were guided by staff memory or through reference books. Consequently, when those staff members left, those who remained often were not aware of previous policies or practices, resulting in an operational change that reflected the philosophy of the staff who remained. The result has been inconsistency in practice and service. The QI initiative is intended to reverse this by improving the quality of the process and using policies and procedures. A QI team was formed and included Jane Ford Witthoff (PHS director), Natalie Kingston (community development), Kim Plouzek (emergency response), Kim Buser (community health services), project lead Adam Zobel (administrative assistant), and other support staff. This QI initiative followed the Plan, Do, Study, Act (PDSA) cycle, and each of these steps is referenced in this submission. The PDSA approach was applicable and successful for this QI initiative because it allowed PHS to draft trial changes and assess their impact. During the Plan and Do stages, ideas for the change were created and tested, and, depending on the results, implemented. The Study stage was used to reflect on the new process and what changes still needed to be made, and the Act stage was used to implement an evaluation method.
Zobel, A. Public Health Quality Improvement Exchange. Increasing Staff Members' Ability to Develop, Revise, and Access Department Policies and Procedures. Fri, 10/10/2014 - 16:30. Available at https://www.phqix.org/content/increasing-staff-members-ability-develop-revise-and-access-department-policies-and. Accessed February 7, 2023.