Policies & Procedures Guide

Develop and implement policies and procedures to ensure pediatric patients consistently receive high-quality emergency care.

PWDC #4 - Policies & Procedures

This flow diagram is designed to help one think about how to break down this focus area into small steps. The questions in this flow diagram align with the environmental scan worksheet in the next section. Consider the primary drivers of an equipment program as you review the following process map:

  1. Communications
  2. Education
  3. Policies & Procedures (yes...policies about policies)
  4. Resources & Tools
  5. Funding
  6. Technology
  7. Culture

Comprehensive policies and procedures are designed to meet the overall goals of pediatric readiness to standardize local care processes and improve outcomes in pediatric emergency care delivery.

  • Policies and procedures may be operational. These provide specific guidance to healthcare staff to optimize resources and processes to meet the needs of children. An operational policy is usually a concise written course of action governing practice, sometimes based on a law, legal code, regulation, accreditation standard, organizational principles or values, or a leadership decision.
  • Policies and procedures may be clinical. These serve to reduce variation in care across patients and/or practitioners which will minimize disparities and optimize quality.

Essential pediatric policies are outlined in the joint policy statements “Pediatric Readiness in Emergency Departments” and “Pediatric Readiness in Emergency Medical Services Systems.” Both policies and procedures—whether they are operational or clinical in nature—are critical to ensuring safe, effective, and high-quality care for all children. Adhering to standardized formats in policy/procedure development decreases confusion, improves understanding, and helps to eliminate gaps in care processes. Once developed and finalized, policy/procedure implementation requires widespread staff training and—at times—tools or resources to foster adherence.

The effectiveness and impact of policies or procedures is dependent upon the extent to which they improve efficiencies and are fully adopted by the clinical team. Securing organizational leadership support is foundational to the establishment of any policy or procedure. Policy or procedure development should begin with collaboration and engagement of stakeholders (leadership and clinical staff). Ideal policies and procedures help to eliminate confusion and create simple yet effective approaches. The involvement of front-line staff in development is key to ensuring each policy or procedure achieves these goals. It should also be noted here that consideration should be given to the extent to which a policy or procedure requires a change in the existing system. A high frequency of these types of changes can be counterproductive and a barrier to uptake of new behaviors as staff are hesitant to adopt a change that will likely be revoked or modified. A thoughtful discussion with your team about how this change might be implemented within the existing structure or perhaps introducing small incremental changes may lead to more complete adoption.

Policies and procedures also aim to streamline the system of care in order for the healthcare team to meet the needs of the patient population. Additionally, clinical policies and procedures and decision support tools create a standard approach to safely managing clinical conditions for which evidence-based content exists. These procedures help ensure all practitioners follow evidence-based recommendations when assessing, treating, and creating a disposition plan. Passive uptake and integration of new knowledge into practice creates significant lags and variability in clinical decision-making. The creation of clinical guidelines and clinical decision-support tools helps drive more rapid adoption of evidence-based guidelines into practice. The development of clinical guidance requires collaboration among stakeholders to adeptly transform evidence into practice based on available resources. Because patient presentation may vary, it is important that clinical procedures address diverse circumstances. Regular monitoring of adherence and effectiveness is important. A standard timeframe for periodic review (e.g., every 2 years) should be set for all policies and procedures to ensure the most up-to-date information is fully incorporated.

See key drivers and change strategies below.

Communication to both staff and leadership around the necessity for the change and ensuring every stakeholder's voice is heard.

Leadership Support

  • Advocate for the importance of including pediatric considerations in existing policies and revisions.
  • Identify key stakeholders that need to be engaged in the development of the policy / procedure (e.g., a policy/procedure committee). Advocate for the importance of including pediatric considerations in existing policies and revisions.

Staff Buy-In

  • Identify potential safety events where clear direction in the form of a policy or procedure would have aided in the care of the child
  • Determine which individuals will be affected by the new policy and develop a process to obtain their feedback or conduct an impact analysis
  • Develop talking points that address the importance of pediatric-centered policies or procedures to ensure the delivery high-quality care

Patient and Family Engagement

  • Engage your family advisory board in the development of policies that may directly affect them (e.g., hospital visitation policies during the pandemic)

Staff will need to be trained on the new policy/procedure to ensure proper implementation

Introduction of a new policy

  • Work with education department/officers to provide just-in-time training
  • Work with education department/officers to determine how the policy or procedure can be integrated into new staff orientation and continuing education

Delivery Method Selection

  • Define most effective and efficient delivery method based on the complexity of the policy/procedure
  • Create a multi-method approach to education on a new clinical procedure to include knowledge acquisition, scenario decisions making and simulation training.

Many organizations have policies or at least a standard process for the proposal, development, and implementation of a new policy or procedure.


  • Determine if you organization has a policy or process regarding the development and implementation of a new policy/procedure
  • Identify a standard format and the key elements that a policy/procedure needs to include at your organization (e.g., inclusion, exclusions, contraindications, process)
  • Develop a standard process for reviewing existing policies/procedures on a defined frequency using a groups that includes a pediatric representative.

Vetting & Approval Process

  • Begin with medical direction, clinical training divisions or other formalized processes for recommending change to the system.
  • Ensure you have an understanding or the organization's vetting and approval process (e.g., department or agency-specific committee, regional EMS committee, etc.).

Review Process

  • Develop an understanding of the organization's schedule for regular review of policies/procedures and ensure your new policy/procedures is included in this process.

New policies or procedures often require a consideration of resources, including the development of checklists, posters and other tools that will be required to support the implementation.

Evidence Base

  • Identify the evidence-base or best practice recommendations with which the policy should align.
  • Reach out to the nearest pediatric center for template policies/procedures
  • Ensure there is transparency on the strength of the evidence.

Knowledge Reinforcement

  • Create a checklist or posters to remind the healthcare team of available care pathways

State / Local Guidelines

  • Ensure alignment with state, regional, or local guidelines and protocols. Include these references in your draft if available.
  • Integrate national quality measures into clinical care pathway

Consideration of the budgetary implications of a new policy or procedure will determine the feasibility of implementation.

Human Resources

  • Estimate the impact that introduction of the policy will have on staff time (e.g. time out of the field for training.)
  • Determine a method to capture the return on investment. (For example, investing X amount of time in staff training should lead to Y percent change in patient outcomes)

Budgetary Implications

  • Determine the cost of purchasing new equipment, supplies, or technologies required as a direct result of the new policy/procedure.

Technology helps ensure staff have easy access to the new policy/procedure as well as assist with monitoring the adherence and effectiveness.


  • Ensure staff have ready access to policies and procedures (e.g, accessible through the patient care report (PCR), electronic medical record (EMR) or an app).
  • Work with the organization's information technology experts to create prompts in the PCR/EMR that promote adherence to the policy/procedure.
  • Explore options to make resources available on smart devices.


  • Identify metrics that can be easily accessed to determine policy/procedure adherence and/or effectiveness
  • Create automated feedback for staff to report challenges with adherence or adoption

An organization's culture around quality and change management, including careful consideration of system hierarchies, will determine the most appropriate approach for implementation.

Change Management

  • Engage influencers, champions, and opponents in the policy/procedure development process
  • Define methods for effective and broad communication of proposed policy/procedure changes and invite input

System Hierarchies

  • Define the organizational hierarchy and utilize that structure to communicate and support new policies/procedures
  • Develop collaborative relationships with system influencers - proponents and opponents to change (e.g. mid-level managers, labor leaders, trusted practitioners)