Writing Policies and Procedures as QA/QI Nurse

Specialties Quality Improvement

Published

hello everyone! I really hope someone can help answer my questions!

I finished my first week of work at my new job as a QA/QI nurse and although the learning experience is a bit overwhelming, I love what I do! I graduated last year and have experience working in the hospital and as a hospice nurse.

I just have a question for you that I hope that you can help me out with. I work for a non-profit clinic that is Federally Qualified Health Center (FQHC) and yearly they are audited by the Health Resources and Service Administration to determine if they still qualify for grants. My supervisor (the CEO) of the company has explained to me that my duty is to maintain the clinical policies & procedures (P&Ps) of the organization, which is one of the things that get audited. I am the first QA/QI nurse to have this position in the organization, and the clinical manager (who is not a nurse nor does have any clinical background) has been writing and maintaining the clinical policy and procedures.

I have no experience in policy making whatsoever and would like to get guidance on how to go about this. Since this is the first position fulfilled for a QA/QI nurse, my resources have been limited and I can't seem to find the answers that I need or any right person from our organization to help me out.

I want to know how to go about writing policies and procedures that comply with certain standards. But I have no idea what standard to go by? Like do I go by HRSA or Clinical Quality Measures (CQM).

The clinical manager who was in charge of the policies and procedures told me that she googled most of the information and copy and pasted some from other P&Ps that she retrieved from other websites. I do not want to go about this protocol of googling and copy and pasting. I want to know how I can use my clinical expertise and what nursing resources I can use to initiate and implement P&Ps. So far there are a lot of P&Ps that the clinic is missing.

Please help me out! Thank you :)

Please help a nurse out!

Specializes in Obstetrics/Case Management/MIS/Quality.

I have heard this site is helpful. It is for the National Guidelines Clearinghouse. Hope it helps...you sound like you have quite the task ahead of you! Good luck in your new position!

http://www.guideline.gov/browse/by-topic.aspx

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