Hospital policy development is an extremely important undertaking. Understandably, clinicians and hospital staff want to know what they can or cannot do and hospital policies provide guidance. Policies are also important because they inform patients and families about their rights and responsibilities with respect to the services they receive. In many urban and academic healthcare settings, ethics committees have a role in policy development, review and evaluation. Research conducted by this project, however, indicates most rural hospitals (60%) lack ethics committees and the ethics committee that do exist are rarely involved in policy development, review and evaluation. Only about a third of the ethics committees had a role in policy activities. Given this finding it can be difficult for rural hospitals to meet the challenges of policy development. To further complicate the issue, policies imply two competing perspectives. Policy involves both process and product. The education materials on policy should therefore be designed to bridge these two perspectives.
There are no hard-fast rules or guidelines for how to begin the process of policy development and subsequent reviews and evaluation. In addition, some of the hospital personnel who may become involved in policy development may have had very little formal training in this area. Generally resources are very limited in rural hospitals which was evidenced in our nurses survey. Only 22% of nurses indicated they had access to any bioethics resources. The vast majority of nurses reported few opportunities for education activities. Given these limitations, some hospitals have found it helpful to overcome this dilemma by starting with cases in which the policy is easily applied and working toward cases in which application is more complex.
It has also been suggested that those working on policy development think of policy as a way to translate the often-abstract mission statement of its hospital into practical terms. Hospital missions often include statements of fair treatment for all patient and standards for treating patients with respect. But, how is that mission actualized when the hospital deals with a patient who has inadequate insurance? And how will respect be shown when the patient refuses treatment that caregivers believe is appropriate? These questions would be a good starting point for thinking about policies.
Generally, policies should be created when they are required by regulation and also when there is a widespread and repeated problem within the hospital, creating a pattern of actions that is inconsistent with the institution's own values. Whether this latter problem should be dealt with through policy or education, or both, should be a topic for serious discussion. It should be noted that all policy writing encompasses both education and policy functions. Although it is advisable to study other institution's policies and refer to the literature on bioethics policies, it is also important for each healthcare setting to think of policy in terms of how it can best reflect the blend of values of its own institution and that of the local community. Adoption of already existing policies without careful reflection and adaptation may render such policies useless.
It is often necessary for hospital ethics committees or other mechanisms to develop policies in order to be in compliance with JCAHO, AHA, PSDA, and other initiatives. This can be a very challenging area because legislative changes can force attention to areas not previously addressed. For example, hospitals may need to develop new policies to be in compliance with Medicare and Medicaid Programs.
Policy development is not only a matter of expertise, it also requires a commitment of time and resources. Data from the our hospital survey indicate that ethics committees differed in which aspects of policy they focused on, depending on the size of the hospital they served and the length of time they had been in existence. Committees serving the larger hospitals (more than 50 beds) and those that had been in existence longer (more than five years) noted policy formulation and evaluation more often than did the ones in the smaller hospitals and the more recently established ones.
The following pages contain materials that may be helpful to rural hospitals as they think about how to develop, review and evaluate policies. Links are provided to the policy writing model, a step-by-step general approach to policy planning and drafting of guidelines for policy development.