Tai M. Paquin, LADAC

As we conclude year three of BH2I-2, we still find challenges such as securing buy-ins from providers, confusion or errors about processes, or oversights made in the delivery of services. In addressing these challenges, the implementation of clear policies and procedures is viewed as beneficial.

Understanding the importance of having policies and procedures is critical to the integrated care clinic for the following reasons.

  • Safety. when protocols are in place, the safety of both patients and providers will clearly define the procedures for handling emergencies or high-risk situations.
  • Efficiency. In tribal health settings where resources can be scarce, they need to be used effectively, processes that reduce duplication of services or methods are vital.
  • Clarity and consistency. When we talk about building trust within a community and system, all individuals receive a standard of care through adherence to the same guidelines. So, if a patient needs a referral the process from initiation to completion is the same for everyone.
  • Accountability. Policies and procedures clearly identify provider roles and responsibilities, which ensures that individuals and teams are held accountable for their actions.
  • Safeguarding information. Policies provide guidance on how the providers record, maintain, and protect health information. Following the procedures ensures that providers provide continuity of care and informed decision-making.
  • Contractual and statutory requirements. Policies help tribal care systems comply with legal, contractual, and regulatory obligations, such as the Indian Health Services (IHS) BH2I Notice of Funding Opportunity (NOFO) and HIPAA.
  • Quality assurance and improvement. Quality management provides a foundation for monitoring clinic performance and collaborations, identifying gaps, and prompts providers to implement improvements to processes. Quality management fosters a culture of continuous quality improvement, learning, and excellence in health care delivery.

Policies serve as the foundational guidelines that dictate how a program intends to manage a specific service or task. For instance, if an organization has a policy regarding the enrollment of clients into behavioral health services, it will establish the objectives, values, and regulations associated with this enrollment process. This policy may also include definitions and designate who is responsible for carrying out the process.

Following the establishment of a policy, the next step is to develop a process or workflow. This aspect generally outlines the actions required to implement the policy. Subsequently, procedures are created to detail how the policy should be executed. They offer specific step-by-step instructions to ensure that tasks are completed effectively in alignment with the established policy.

We recognize that developing and formalizing policies and procedures is not a quick or an easy task. However, we encourage you to start discussions within your agencies and with your T/TA providers about how to begin this process if you haven’t already. We are here to support you as thought partners throughout this journey and can provide templates to help get you started, if needed. Examples of policies and procedures can also be found on the BH2I Toolkit website at www.bh2itoolkit.com.

So, as we enter Year 4 of the BH2I-2, it’s clear that having policies and procedures isn’t just a requirement or helpful, it’s essential to overcoming the challenges we face. They provide structure and guidance, making sure everyone is on the same page and that services are delivered safely, consistently, and effectively. In developing good policies and procedures we work smarter, solve problems, and continue making a positive difference for the communities we serve.

References:

Strasser, P.B. & Randolph, S.A. (2006). Developing Policies and Procedures. AAOHN Journal, 54(11), 501-504. doi:10.1177/216507990605401104