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Policies and Protocols in Healthcare

In today’s healthcare environment, policies and protocols are essential, as they guide medical professionals in providing high-quality, evidence-based care to all patients. These documents can also reflect ethical considerations involved in care provision, thus ensuring compliance with relevant professional codes of ethics. Therefore, policies and protocols help to promote patient outcomes and the ethical conduct of employees. The present paper will discuss policies and protocols in my clinical setting, which is a primary care clinic providing care to elderly patients.

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My institution has several important policies and protocols that can be viewed in a policy book. An electronic copy of the policy book is freely available to all employees, and there are several physical copies of the book in the facility. The topics covered in these policies and protocols include all of the operations, processes, and procedures of the clinic. For example, the policy book contains protocols related to admission, discharge, and transfer of patients. There are also specific protocols for using electronic health records and referring patients to health professionals in other clinics.

The person responsible for the oversight of these documents is the administrator. She ensures that policy books contain all the relevant documentation and are readily available to staff when needed. New policies and procedures are developed by the compliance committee, the administrator, and the Medical Director. The team meets quarterly to determine the need for a new policy or procedure, collects evidence, creates the document, and adds it to the policy book. Policies and procedures are also subject to quarterly or annual reviews by the compliance committee and the Medical Director to reflect changes in treatment approaches, ethical standards, and other guidance documents.

If changes to the current policies are made, they are immediately applied to the policy book, and all relevant employees are notified. The compliance committee is also tasked with ensuring that employees comply with all the policies and procedures. Whenever patients or other employees voice their concerns with an employee’s behavior, an internal investigation is carried out to identify if there were indeed any compliance issues.

One particular area for improvement with regards to enhanced collaborative practice and optimal patient outcomes is the continuity of care. At present, the clinic does not have a specific policy stipulating the procedures aimed at ensuring the continuity of care, although it has connections with long-term care facilities and home care services for elderly patients. Continuity of care is critical to improving patient outcomes and developing collaboration with other institutions and care providers (Bayliss et al., 2015). Besides, higher continuity of care results in increased patient satisfaction and lower care costs (Barker, Steventon, & Deeny, 2017). Designing a specific policy containing procedures for improving continuity of care would thus benefit both the patients and the facility.

To conclude, policies and protocols are critical to clinical practice, as they improve care quality and help to address various ethical considerations. My practice clinic has a comprehensive range of policies and protocols that are updated regularly, which helps to promote patient outcomes. Nevertheless, the clinic lacks a strong continuity of care policy, which might affect the results of the services provided. The clinic needs to develop and implement a specific continuity of care policy to improve cooperation with other facilities and providers, increase patient satisfaction with services, and reduce costs.


Barker, I., Steventon, A., & Deeny, S. R. (2017). Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: Cross sectional study of routinely collected, person level data. BMJ, 356(j84), 1-9.

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Bayliss, E. A., Ellis, J. L., Shoup, J. A., Zeng, C., McQuillan, D. B., & Steiner, J. F. (2015). Effect of continuity of care on hospital utilization for seniors with multiple medical conditions in an integrated health care system. The Annals of Family Medicine, 13(2), 123-129.

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