M A Y 2 0 1 6 • O U T PA T I E N TS U R G E R Y. N E T • 1 9
A
ccreditation agencies require very specific policies. In order to stay on top of their
requirements, we've organized and aligned our policy and procedure manual to fol-
low the same order as the chapters of our accreditor's handbook. From regulatory
compliance and patient care to safety and facility management, it's all there and easy to verify
that we have the necessary policies and procedures in place.
Standardizing and systemizing your policies to conform to an accreditor's model can be a taxing
project that takes several months and the involvement of both leadership and staff. But whether
your manual is a binder with dividers or a read-only file on the computer network, the results
handily show surveyors that your facility's guiding documents, and its operational practices, meet
their demands.
Martha Colen, RN, BSN, MBA, CASC
Virginia Beach (Va.)
• CHAPTER AND VERSE OR director Libby Bozeman, RN, CNOR (left), and Amy Westphall, RN, BSN, manager of surgical
services and PACU, consult the policy manual.
Organize Your Policies Like Your Accreditor Does
Martha
Colen,
RN,
BSN,
MBA,
CASC
Ambulatory Surgery Center
mrcolen@sentara.com
