Point of Care Policies.

We have SoftTech for document control. Our POC procedures are nursing procedures but POC is the "owner" so we are responsible for the reviews/updates, etc. If the change is major the procedure goes to a committee for review.

Nursing is owner/responsible for medical (not POC SOPs) procedures and policies related to staffing. Onboarding and competency based orientation tools including POC activites are nursing-held tools. All POC procedures/SOPs, QC logs, and POC governance policies are held by laboratory services using their record documentation/MediaLab.

We have Policy Stat and all POC testing policies are under POC (me). Any P/Ps that relate to "how" patients are treated in reference to a POC test are under nursing (i.e. I have the Accuchek Inform II policy on how to perform the test and QC ect, nursing has a policy on how to treat patients based on the result from the finger stick glucose.)

I am considered the originator (creator) and do the updates, editing and creation. I do have a POC Steering committee that reviews any changes prior to it going out for review (the committee is lab, nursing, compliance, distribution and clinic leads). Policy Stat allows for specific approval workflows depending if it is a general nursing policy (like glucose monitoring) or if it is clinic specific (like HA1C). The workflows include the nurse managers, clinic leads, Nursing leads, MD (if needed) and VP over which ever service line the policy is for.

If there are major changes that have taken place, I work with our Training and Education department and the Clinical Nurse Educators to put out the new information and train staff.

Until I took this position, nursing owned the policies and there were multiple versions of the same policy out there depending on which nursing group was in the process of updating it. Having Policy Stat has helped contain the revamps and ownership.

Our POC SOP's are owned by lab. We have our own electronic policy system called Omni, but the only people that are assigned as owners and reviewers are the POC team and the lab Medical Director. Once approved, I submit them to the hospital Clinical Policy and Procedure Committee as a PDF, and she publishes them on the nursing policy Sharepoint. They do get hospital CMO and CNO approval as part of that process.