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Formulating Internal Policies and Procedures
Administrators at hospitals, nursing homes, outpatient surgical centers and small medical practices often feel that it is in their best interests to draft a comprehensive set of written policies and procedures. A written set of policies can make a provider appear to be less vulnerable to litigation, and more organized. Frequently, written policies and procedures are used to instruct nurses or other non-physician employees on the protocols for a variety of activities. This practice can make training and employment performance issues easier for the provider. However, it can also expose the organization to criticism when these seemingly arbitrary policies are not precisely followed.
It is rare that a medical provider will draft a policy or procedure on the medical “standard of care” and how medical personnel should apply it to patients. However, occasionally a plaintiff is able to argue that a policy that a provider intended to be procedural creates a self-imposed standard of care. In these cases, depending on the jurisdiction, the health care provider may have to defend the violation of its own policy or procedure, even if the policy goes above and beyond the national standard of care. This is why great care must be taken when drafting and implementing written policies and procedures for medical care organizations.
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