Programmatic Issues – Developing Policy and Procedure

Background:
As recommended vaccines increase, more doses are distributed and the associated cost and accountability rises. The Maine Immunization Program (MIP) recognizes the need to provide clear and concise standardized policy and procedure in order to better serve providers in a consistent way.

Setting:
MIP

Population:
MIP Staff

Project Description:
MIP developed a Quality Management Plan for policy and procedures that includes guidance covering assurance of use, methods of distribution, reviewing and approving, and identifying how historical documents are stored. To facilitate development of policy and procedure, MIP staff was asked to identify tasks they perform. For each task, they were asked to provide information, i.e. steps to describe the process; software systems used; frequency of occurrence; reference manuals; and barriers that may hinder completion. Using internally developed templates, procedures were created and then tested by having inexperienced people walk through processes as outlined. As a result, any missing instruction or information was identified and revisions were made. Policies were developed that ensured procedures would be followed consistently. Reference to national standards or grant requirements is included in applicable documents.

Results/Lessons Learned:
The MIP has provided consistent information for staff, used the information for training purposes, maintained quality control and quality assurance processes and helped to ensure compliance with CDC requirements. Procedures must contain all information necessary to perform each process. When necessary, a flow chart or screen shots to illustrate the process being described should be used. Considerable time and effort must be dedicated to development efforts. Copies of up to date procedures should be located in work areas of those individuals performing each activity. An evaluation and review system will ensure that policies and procedures are correct and appropriate.
Sample of policies, procedures and flowcharts will be presented.