Policy & Procedures Committee

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    Does anyone have or participate in a policy & procedures committee in their OR? We have never actually had one in our OR before that consists of the staff members from all of our departments -> Preop, OR, and PACU, and I am kind of looking for some guidance from others as to what types of things are discussed and what are the roles/responsibilities of each staff member that is on the committee. Thanks for the help!
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    Quote from JoeTheRN
    Does anyone have or participate in a policy & procedures committee in their OR? We have never actually had one in our OR before that consists of the staff members from all of our departments -> Preop, OR, and PACU, and I am kind of looking for some guidance from others as to what types of things are discussed and what are the roles/responsibilities of each staff member that is on the committee. Thanks for the help!
    We have one. There are 2 members assigned from each department to gain staff feedback on policies that they feel should be reviewed (i.e. too ambiguous, outdated, overburdensome, etc.) and those policies are reviewed. The committee then meets with other collaborating team members. The chair then meets with the director to discuss changes. The whole process on one policy change takes months. Here's two examples:

    Emergency ERCPs after hours and on the weekend:

    Previous policy stated that a GI nurse and GI tech had to come in from home when there was an emergency ERCP scheduled. We staff the OR at all times with at least 2 full teams, so they were able to change the policy that only a GI tech would need to come in from home on these cases, and one of the OR nurses that's already "in house" would be the nurse. The only reason why a GI tech still has to come, is because we don't know their stuff. Sucks for the tech, but it made the GI nurses happy.

    Another example: ICU admits from the OR

    Previously, if a patient was extubated in the OR, but was an ICU admit, they had to be recovered in PACU, before going to ICU. You know the PACU nurses were not happy about that. The policy was changed, so now if the patient is an ICU admit or returning to ICU, they go straight to ICU from the OR, whether they're intubated or not. This policy change involved the collaboration of OR, PACU, ICU, and the anesthesia staff.
    (You know ICU nurses are not happy.)

    I'm sure you'll get more requests for policy changes, than you'll want. Everyone has a complaint about something. Good luck.


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