Merging Policies System Wide Ensure Patient Safety - Crozer-Keystone Health System - PA

Merging Policies System Wide Ensures Patient Safety

Kathy Layton, RN, MSN, BC, BA

To achieve the highest levels of patient safety, the best evidence-supported practices should be used by all nurses throughout the system. This will not only ensure excellent, state-of-the-art care by nurses, but it also will assure patients that the care they receive will be consistent no matter which CKHS facility they choose to go to throughout their lifetimes. In addition, the Supplemental Staffing nurses who assist with staffing needs throughout the system will be assured that standard practices will be the same at every hospital. This will increase nursing’s ability to provide safe care and safe environments and improve patient outcomes.

The CKHS Standards of Practice Development Subcommittee charged with this challenging responsibility is co-chaired by Kathy Layton, RN, MSN, BC, BA, nurse educator at Delaware County Memorial Hospital, and Ann Orner, RN, Crozer-Chester Medical Center. The committee includes the chairs of each of the Nurse Practice Councils (NPC); an educator and an administrator/nurse manager from each hospital; Jeannine Wilk, RN, BSN, MA, BSBA an Information Systems representative; and Zanet Lester, RN, BSN, MSHA, CKHS Center for Nursing Excellence coordinator.

Ann Orner, RN

The committee’s first task has been to combine all policies and procedures, plans of care and protocols into one CKHS Standards of Care Manual. When the committee first met in November 2008, they quickly discovered that each hospital was speaking a different language in the nursing manuals. “What one hospital called a policy, another called a procedure,” Layton says. “What one hospital called a plan of care, another called a protocol and still another called a practice guideline. Even the title to the manual was different at each hospital. So, the first order of business was to develop a common language. Once this was done, then all the committee members were able to speak to each other more clearly about a particular document.” (See chart below.) 

In subsequent monthly meetings, the committee began to tackle the many aspects of merging policies. Besides developing a common “language” to use, they decided on the format for the policies and merged all policies into one index. “We designed the index to include all possible terms that a nurse might use to look up a policy, keeping in mind that each hospital has been using different terminology,” Layton says. “In the future, after everyone becomes accustomed to the standardized language, we will condense the index.” 

At this point, the plan of care section is nearly complete and the committee is focused on policies and procedures. With about 70 policies to review and standardize, this section is by far the most time-consuming, according to Layton. “We have a room full of nurses who value the way things have been done at their respective hospitals, yet they have a fantastic attitude about reaching compromises. In some cases, these compromises represent a big change for one hospital and almost no change for another, but everyone is committed to adopting the best practices. To that end, we are researching evidence based practice and thoroughly reviewing the details of each policy,” Layton says. 

The committee expects to complete the main Standards of Care Manual in 2010, but their work will be far from over. Next they will begin work on the specialty manuals. When it is time to review the more intricate specialty manuals, Nurse Practice Council representatives from all CKHS hospitals will meet to develop evidence-based practice policies. 

After the manuals have been completed, the committee will continue to meet periodically throughout the year to review any proposed edits, updates or newly developed policies and procedures to the main manual. Currently, the committee is developing algorithms to guide nurses in submitting new policies or revising existing policies.

“We encourage all nursing staff to bring their insights or concerns about a particular policy to their unit NPC reps, who will then bring those suggestions to their NPC meeting,” Layton says. “The chairs will note the suggestions and bring them to the system-wide committee for review. This is nursing’s opportunity to look at our current practice and make sure we are offering our patients the most up-to-date care possible. This process allows each of the facilities to share best practices with each other and to assist each other in problem solving difficult situations. Each facility has nurses providing excellent nursing care and sharing successes will only benefit all CKHS nurses.”

Layton emphasizes that ongoing communications and education will be integral to the rollout of the new CKHS Standards of Care Manual. As each section of the manual is completed, a newsletter will be issued reviewing the policies in that section. These newsletters will be kept in a binder on every unit for nurses to review. When the Standard of Care Manual is fully completed, a roll-out date will be selected (at least 45 days in advance). That time frame will give staff ample opportunity to review the newsletters and be prepared for the new Standards of Care Manual distribution.

Ultimately, the new manuals will be available on the CKHS Intranet. “With one click, the nursing staff will always have the most current policy available,” says Layton. 

“The nurses who came forward to work on this critical project came with trepidation at first,” concludes Layton. “But they have came together as a great team, working together to develop a manual that will ensure the best possible patient care throughout all Crozer-Keystone facilities.”

CKHS Standards of Practice Development Subcommittee

Kathy Layton, RN, MSN, BC, BA - DCMH, Co-Chair

Ann Orner, RN - Crozer, Co-Chair

Dina D’Alonzo, RN – Taylor

Deborah Love D’Elia, RN, MSN, MBA - Crozer

Sharon Dougherty, RN – Taylor

Zanet Lester, RN, BSN, MHCA – CKHS

Kathy Manuel, RN, MSN, OCN – DCMH

Leslie Mickles, RN, MSN, Ed.D(c) – Crozer

Roe Mitchell, RN – Springfield

Kathy Poole, RN, BSN, CCRN – Crozer

Susan Simonson, RN, BSN – Taylor

Jeannine Wilk, RN, BSN, MA, BSBA, MCP - CKHS








Manual Title

Standards of Care Manual

Nursing Practice Manual:

Practice Guidelines, Polices and Best Practice Protocols

Standards of Care

Plans of Care

“Care of the Patient…”


Practice Guideline

Plan of Care

Step by step procedure guidelines



Policy and Procedure

Nurse Driven Protocols approved by MEC

(i.e.: Foley Use; Vaccines)


Best Practice Protocols



Manual Title

Standards of Care

“Care of the Patient…”

Plan of Care

Step by step guidelines

Policy and Procedure

Nurse Driven Protocols