Protocol Development and Quality Improvement
Write the final draft.
Document the date that the policy was ratified and then subsequent review dates.
Committee review and approval.
Incorporate the new policy into the policy and procedures.
Communicate the new policy to all relevant people.
Identify policy review process.
Formal process may be required within the institution (i.e., standing policy and procedures
committee, which develops and reviews the policy and provides recommendations and decisions).
Involvement and approval from the P&T and critical care committees or other oversight committees
Create education for the key stakeholders (e.g., physicians, advanced practice providers, nurses,
pharmacists, dietitian, respiratory therapists).
grand rounds, one-on-one direct education, online learning modules, etc.
Assessment of education through annual competency examination, skills assessment, monthly
simulation modules, etc.
Review of existing policies. Continuous QI requires documentation and training for pharmacists and staff.
Many state boards of pharmacy are requiring reportable events to be identified and documented. Policies
and procedures can also be developed for analyzing the data collected to assess causes and contributing
factors so that findings can be used to improve outcomes.
Every policy should regularly be reviewed for relevance and appropriateness (e.g., every 1–3 years),
depending on organizational structure/standards.
Things to consider when reviewing a policy:
Determine need for updates to the policy.
Evaluation strategies
Ongoing monitoring
| d. | Presentation of data |
|---|
Consumer feedback
Stakeholder feedback (e.g., physician, pharmacy, nursing, policy steering committee, critical care
committee)
Planning day agenda
Forms: Data collection sheets, data reporting format, questionnaires
Key stakeholder questionnaires
Review evidence-based critical care literature and clinical practice guidelines in designing a patient-
specific plan of care
Definition: “The conscientious, explicit and judicious use of current best evidence in making
decisions about the care of individual patients. The practice of evidence-based medicine means
integrating individual clinical expertise with the best available external clinical evidence from
systematic research.” (BMJ 1996;312:71)
Pros and cons of evidence-based medicine (EBM)
Advantages
| (a) | Critical appraisal skills of the literature improve with the review of EBM. |
|---|---|
| (b) | Wasteful, outdated, or harmful practices can be abandoned. |
| (c) | Presupposes that we keep up-to-date; ideally, a systematic process of incorporating new |
EBM is included