Protocol Development and Quality Improvement

Interdisciplinary team effort: Patient, physician/prescriber, nurse, respiratory therapist, pharmacist,

clinical dietitian, physical therapist, social worker and/or case manager, hospital administrators, and

patient’s family/support network

Voluntary – Allows for deviation depending on clinical scenario

Protocol can be an extension of a clinical policy or procedure.

Clinical guidelines and protocols are often kept separate from institutional policies and procedures.

Examples of disease management guidelines include:

Pulmonary embolism therapeutic management

Pain, Agitation, Delirium, Immobility, and Sleep (PADIS) management

Spontaneous awakening and breathing trials

Critical care pathways

Consider ways to incorporate guidelines/protocols into CPOE to facilitate ordering and monitoring

in conjunction with the guideline/protocol.

Critical care pharmacists should lead, or be actively involved with, the assessment of medication-related

guidelines, protocols, practice changes, or PI initiatives in the ICU.

Purpose – For whom the policy is intended, why the policy is needed, and the desired goals

Intent of the policy

Provisions

Procedure

Resources/references

Owner

Date created/modified/last reviewed

Approvals

Planning

Define and prioritize policy goals and objectives.

Identify key stakeholders and include them in the policy development process.

Appoint a project facilitator/leader.

Develop a strategy for tracking and managing each group’s progress.

Solicits input from organizational or external stakeholders

Promotes good relations between sites and service providers

Encourages participation and feeling of ownership in the process

Alternative viewpoint may identify inconsistency, ambiguity, and/or duplication.

General steps in drafting

Write a first draft.

Distribute the draft, and consult across the same organization/stakeholders/experts for comments.

Review feedback, both written and verbal, and amend/revise the draft.