home | ABOUT THE IAC | THE IAC DIVISIONS | ACCREDITATION | IAC NEWSLETTER | EXHIBIT SCHEDULE | CONTACT THE IAC

IAC Newsletter

The development, implementation and maintenance of clearly written policies and procedures is one of the key elements in achieving successful outcome of a process and, ultimately, improved patient care.

Policies and procedures are considered integral components of a quality magnetic resonance laboratory and, as such, are required in several areas, as defined within The 2008 ICAMRL Standards, Part I: Magnetic Resonance Imaging Operations - Organization. Throughout Section 5: Safety and Patient Confidentiality, the specific areas where policies and procedures are required are outlined and it is explained that they must be written, enforced, reviewed and documented annually by the Clinical MR Director.

When preparing for accreditation, a large majority of the participating laboratories report that they find writing policies and procedures to be the most challenging part of the process. However, regardless of the laboratory's intention related to accreditation, these documents are crucial to the laboratory's operations.

Who benefits?

Having written policies and procedures provides benefits to the patients, as measures are taken to continually evaluate and implement processes to make the MR environment safe. Personnel also benefit, especially in emergency situations, where action is essential and thought processes are blurred. Well-written policies and procedures allow the medical professional to focus on what needs to be done to help the patient.

Applicant laboratories are required to have an overall quality assurance program that addresses patient care issues and are required to submit documentation of such policies and procedures as part of the application. In conjunction, a Quality Assurance committee that develops, implements, and evaluates the policies and procedures of the quality assurance program is required. The committee provides oversight and guidance to put corrective action in place where deficiencies are noted.

What is required?

The ICAMRL requires applicant laboratories to submit policies and procedures that address various functions within the laboratory, such as patient safety and confidentiality; patient screening; infection control; emergency care; image quality; and the reporting process.

Definitions

Policy
Policies reflect purpose of the process, the "rules" governing the implementation of a process, and who will benefit from the implementation of this policy.

Procedure
A procedure is the step-by-step instructions to implement the policy. Procedures can and should be updated as new processes are designed, or as an area changes in response to the internal or external environment.

Why?

Written policies and procedures benefit the laboratory by promoting quality patient care in several ways.

Written policies and procedures help:

• prevent mistakes
• focus on the task at hand, especially in emergency situations
• save time
• ensure consistency and improve quality
• train new employees
• improve deficiencies

Written policies and procedures can also be used as a management tool, both from a recognition standpoint as well as grounds for discipline. Deviation from certain laboratory procedures may warrant counseling, additional training, or possibly termination.

Communication in the laboratory is paramount. Having clear, detailed written policies and procedures may help avoid many workplace communication problems before they begin.

How?

POLICY AND PROCEDURE GUIDANCE

What are the characteristics of good policies and procedures? The overall goal for any policy or procedure document calls for the design to be simple, consistent, and easy to use. A consistent format between policies and procedures is recommended as this facilitates changes and allows for recognition of the documents.

Components of Good Policies:

• Policies are written in clear, concise, simple language.
• Policy statements address the rule itself, rather than how to implement the rule.
• Collectively, policies represent a consistent, logical framework for laboratory function.

Components of Good Procedures:

• Procedures are tied to policies.
• The relationship should be explicit with regards to how the procedure helps the laboratory achieve its goal.
• Procedures are developed with the customer/user in mind. Well developed and thought-out procedures provide benefits to the procedure user. Ideally, there is a sense of ownership amongst procedure users. Therefore, it is beneficial to involve the ultimate users when developing procedures.
• The procedures are understandable. Procedures should be written in a format allowing the steps to be easily followed by all users.

Suggested Writing Style for Good Policies and Procedures:

• Concise, minimum use of verbiage
• Factual
• Avoidance of including information that may quickly become outdated (e.g., names)
• Spelling out of acronyms the first time they are used
• Inclusion of step-by-step instructions
• Written in a tone to be understood by all employees, regardless of their amount of tenure with the laboratory

The Quality Assurance committee should act as the policy and procedure "owners", and as such is acountable for the timely review, updating, and dissemination of the documents to those in the laboratory. Assignment of responsibility for policies or procedures may be accomplished through a series of delegations of authority to specified laboratory staff members.

1 | 2 | NEXT>>