Protocol Development and Quality Improvement
Objective: Critical care pharmacists should participate in developing ICU and institutional policies, procedures,
guidelines, and education.
Policy – A course or plan of action; written policies establish standards of practice or quality/compliance
measures and protects against error. Policies intend to show the “why” behind an action and include
a description of “what,” “when,” “who,” or “where” actions should occur in a specific situation. Most
policies are mandatory and may result in disciplinary action if not followed. Policy is based on well-
defined standards including those that may be required to comply with laws, regulations, or contracts.
Benefits
Improves consistency and efficiency of work processes
ii.
Provides a training tool during a new employee’s orientation
iii.
Provides reference material for education and practice
iv.
Minimizes practice variations
Reduces the organizational risk by mandating compliance
Development and implementation should involve all relevant team members to ensure all concerns
are addressed and to promote input from all stakeholders.
Examples of policies:
Acute pulmonary embolism response team
ii.
High-alert medication list and safety standards
iii.
Pharmacist initiated automatic therapeutic interchange
iv.
Pharmacist-initiated intravenous to oral conversion
achieve a desired result or accomplish a task in a consistent manner; the “how” to achieve the desired
outcome or comply with a stated policy.
Requires approval by the organizational committee
Describes each team member’s responsibility
Defines the expected outcome(s)
| d. | Procedures may be described in the following forms: |
|---|
Written instructions
ii.
Flowcharts
iii.
Checklists
Can be used as a QI tool or a source of measures
Examples of procedures:
Central line placement
ii.
Medication event reporting
iii.
Use of the AddEase Administration System
iv.
Downtime procedures during system outages or natural disasters
clinical circumstances. Should include all aspects of care including the following: Patients that are excluded
from the treatment or have contraindications, initiation criteria, dosing (if applicable), titration, monitoring,
education, duration of therapy, etc.
Supports clinical decision-making by defining best practice
Developed by examining the evidence and gaining consensus among practitioners