Policies and Procedures

“If you could break or change any rule in service of a better care experience for patients or staff, what would it be?”

Berwick et al., 2017

Organization-specific policies and procedures may create unnecessary burdens on staff and potentially harm patient care. Regulatory requirements and payment rules can be misinterpreted and lead to more stringent than necessary protocols (1). Organizations can align their rules more effectively and relieve worker stress by considering the following:

  • Collaborate with direct care staff and patients to identify senseless obstacles and rules that contribute to work stress, impede workflow, or negatively impact care delivery (1, 2, 3, 4).
  • Contact regulatory bodies to clarify rule scope/intent and align the policies to match without added burdens. (1, 3)
  • Work in partnership with nurses to identify solutions to common issues such as accessibility or wait times 1, 2).
  • When writing new rules, include direct-care staff in policy decisions (1, 2).
  • Remove any restrictions/requirements that are not mandatory and contribute little or no value to patient care. (1, 3, 4)
  • Write policies and job descriptions for all roles to work to top of license, education, and training. (1, 5)


  1. Berwick, D. M., Loehrer, S., & Gunther-Murphy, C. (2017). Breaking the Rules for Better Care. JAMA, 317(21), 2161. https://doi.org/10.1001/jama.2017.4703
  2. Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D (2017). IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement. (Available at ihi.org)
  3. National Academies of Sciences, Engineering, and Medicine, National Academy of Medicine, & Well-Being, C. O. S. A. T. I. P. C. B. S. C. (2020). Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being (1st ed.). National Academies Press.
  4. Kohl, R., Calderon, K., Daly, S., & Hanson, C. (n.d.). Reducing Administrative Burden: Refocusing on Patient-Centric Care. TMF Health Quality Institute. https://www.tafp.org/Media/Default/Downloads/practice-resources/TMF-admin-burden.pdf
  5. Bergey, M. R., Goldsack, J. C., & Robinson, E. J. (2019). Invisible work and changing roles: Health information technology implementation and reorganization of work practices for the inpatient nursing team. Social Science &Amp; Medicine, 235, 112387. https://doi.org/10.1016/j.socscimed.2019.112387