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Hi all, 

Our organization will be rolling out a new use of standard operating procedures for patient care, and our nursing leaders want to ensure that nursing shared goverance is able to provide input.

Does anyone have any experince with this, and how does your organization go through the processs of reviewing/creating SOPs and the approval process? Any tips, suggestions or advice to offer? 

I look forward to any insight! 

Hi Caterina,

in our setting, we have a clerks SOP that outlines the process for handling various requests that come from our patients. It includes how to complete records requests, medication refills, referral renewals, how to report urgent complaints, scheduling process's for each specialty (acute vs follow-up vs routine), etc. It was initially created by a department head and business manager (both of which are always staffed by a MD, NP and/or BSN/MSN RN) using organizational policy, EBP and preference. It is reviewed and updated annually to reflect any change in procedures by the same leadership. We also have one for nursing process, and one for medical assistant process. Ours were recently heavily neglected during the pandemic and our department head at that time was also a 0.9 FTE MD. We are updating them all at this time to reflect 2025 from the last update and review in 2021. It's been a cumbersome task. Good luck, and I hope you get the insight you need! 

Hi all, 

Our organization will be rolling out a new use of standard operating procedures for patient care, and our nursing leaders want to ensure that nursing shared goverance is able to provide input.

Does anyone have any experince with this, and how does your organization go through the processs of reviewing/creating SOPs and the approval process? Any tips, suggestions or advice to offer? 

I look forward to any insight! 

Hi all, 

Our organization will be rolling out a new use of standard operating procedures for patient care, and our nursing leaders want to ensure that nursing shared goverance is able to provide input.

Does anyone have any experince with this, and how does your organization go through the processs of reviewing/creating SOPs and the approval process? Any tips, suggestions or advice to offer? 

I look forward to any insight! 

Good Morning Caterina!

We are exploring a multi-modal approach to this process, as it can be quite challenging to get everyone to the table. We have found the most success with the team-based care model. For specific SOPs that affect only one practice site, the site will have volunteers from each clinical team join forces to draft an evidence-based SOP, and perform a PDSA. Once it is deemed successful by their teams, the draft SOP is submitted to a policy and procedure committee made up of stakeholder leaders for evaluation and approvals. Perhaps you could include your nursing shared governance at this stage?

For more general SOPs that impact multiple practice sites, stakeholder practices will send representatives from each of their clinical teams to a larger committee, and follow the same process, incorporating feedback from all stakeholder sites.

Hi all, 

Our organization will be rolling out a new use of standard operating procedures for patient care, and our nursing leaders want to ensure that nursing shared goverance is able to provide input.

Does anyone have any experince with this, and how does your organization go through the processs of reviewing/creating SOPs and the approval process? Any tips, suggestions or advice to offer? 

I look forward to any insight! 

Emma, 

Thanks for your great suggestions, and appreicate you sharing!

I am exicted and a little nervous as I am still relatively new in my role even though I have been in different roles in my organization. 

Take care! 

Best, 

Cat 

Good Morning Caterina!

We are exploring a multi-modal approach to this process, as it can be quite challenging to get everyone to the table. We have found the most success with the team-based care model. For specific SOPs that affect only one practice site, the site will have volunteers from each clinical team join forces to draft an evidence-based SOP, and perform a PDSA. Once it is deemed successful by their teams, the draft SOP is submitted to a policy and procedure committee made up of stakeholder leaders for evaluation and approvals. Perhaps you could include your nursing shared governance at this stage?

For more general SOPs that impact multiple practice sites, stakeholder practices will send representatives from each of their clinical teams to a larger committee, and follow the same process, incorporating feedback from all stakeholder sites.

Hi all, 

Our organization will be rolling out a new use of standard operating procedures for patient care, and our nursing leaders want to ensure that nursing shared goverance is able to provide input.

Does anyone have any experince with this, and how does your organization go through the processs of reviewing/creating SOPs and the approval process? Any tips, suggestions or advice to offer? 

I look forward to any insight!