Emergency Department Policy Development Toolkit

Overview

Policy development in the ED is a structured improvement process. It should follow a predictable, transparent pathway to ensure safety, regulatory compliance, and clinical adoption.

The Policy Development Lifecycle

1. Identify the Need
2. Define the Problem
3. Assemble the Team
4. Review Evidence & Regulations
5. Draft the Document
6. Stakeholder Review
7. Governance Approval
8. Education & Implementation
9. Monitor & Measure
10. Sustain & Revise

Defining scope, leadership, timeline, and ownership before drafting is essential. Use a customizable project charter template to ensure alignment on goals and accountability from the start.

A standardized, ready-to-use ED policy template that ensures clarity, regulatory alignment, defined roles, procedural steps, competency requirements, and measurable outcomes. Designed to support safe, consistent, and operationally integrated clinical policies.

Before submitting for governance approval, verify:

✓ Multidisciplinary review completed
✓ Pharmacy review (if medications are involved)
✓ Risk management review (if high risk)
✓ IT review (if EMR changes required)
✓ Equipment availability confirmed
✓ Scope-of-practice alignment verified
✓ Documentation workflow tested
✓ Competency plan finalized

A. Education Plan Template

Target Audience:

Education Methods:

☐ Staff meeting
☐ Microlearning module
☐ Simulation
☐ Case-based review
☐ Email summary
☐ Quick-reference card

Education Completion Deadline:

B. Clinical Integration Checklist

☐ Order sets updated
☐ Smart phrases created
☐ Equipment standardized
☐ Visual aids posted
☐ Badge cards distributed
☐ Simulation conducted
☐ Huddle messaging initiated

C. Go-Live Communication Template

Dear [Insert Name],

On [DATE], the Emergency Department will implement the updated __________________ policy.

Key changes include:

All staff must complete the required education by [DATE].

Please direct questions to __________________.

Sincerely,

[Insert Name]

Structured templates to evaluate compliance, identify barriers, and guide 30-60-90 day review processes. Supports data-driven oversight, audit tracking, and continuous policy refinement.

Policy Ownership

Every policy must have:

• Named content owner
• Defined review cycle (e.g., every 3 years)
• Trigger events for revision
• Annual education refresh plan

Sustainability Checklist

☐ Named owner identified
☐ Review date scheduled
☐ Data monitoring ongoing
☐ Annual competency included
☐ Policy accessible in the system
☐ Orientation integration complete

Week/Milestone

1–2 weeks: Problem defined, team assembled

3–4 weeks: Evidence review completed

5–6 weeks: Draft created

7 weeks: Stakeholder review

8 weeks: Revisions

9 weeks: Governance approval

10-11 weeks: Education rollout

12-15 weeks: Go-live

16 weeks: First review

High-risk policies (sedation, airway, sepsis, trauma) may require 3–6 months.

Pitfall/Prevention Strategy

Writing in isolation: Build a multidisciplinary team

Overly complex language: Use clear, directive statements

No workflow integration: Update EMR and equipment

No competency plan: Include training section

No measurement: Define metrics before go-live

No ownership: Assign named policy steward

If you are new and unsure where to begin:

1. Write a 2-sentence problem statement.
2. Identify 3–5 stakeholders.
3. Review 2–3 national guidelines.
4. Draft the purpose and scope first.
5. Write policy statements before procedure steps.
6. Keep procedures chronological.
7. Define metrics before approval.
8. Plan education during drafting.
9. Schedule a 90-day review before go-live.