Section 19.2: Policy Development and Standardization

19.2.1 The “Why”: Policy as the Blueprint for Standardization

In the previous section, we established the critical governance structures—the committees—that make decisions. But what is the tangible output of those decisions? How does a consensus reached in a Clinical Advisory Group meeting transform from a line in the meeting minutes into a consistent, reliable, and enforceable practice for thousands of clinicians across an entire health system? The answer is through the deliberate development and implementation of policy.

In the context of health informatics, a policy is far more than a dusty binder on a shelf. It is the official, documented embodiment of the organization’s standard of care. It is the constitution that governs the digital medication-use process. A well-crafted policy serves as the definitive source of truth, eliminating ambiguity and clinical variation where it is unsafe or inefficient. It provides the necessary authority for building standardized tools—like order sets and alerts—and creates the framework for holding users accountable to best practices. Without a strong connection between governance decisions and documented policy, even the best ideas will fail to be implemented consistently, leading to the very chaos that governance is designed to prevent.

Consider the common challenge of managing verbal orders. If there is no clear, enterprise-wide policy, every unit may handle them differently. Some may allow them for any medication, while others restrict them. The documentation process may vary. This inconsistency is a massive patient safety risk. A strong policy, developed through governance, would clearly define the limited, emergent circumstances under which verbal orders are acceptable, specify the required read-back and documentation standards, and then—critically—this policy would be used as the blueprint to design the EHR’s verbal order functionality. The policy provides the “why” and the “what”; the informatics build provides the “how.” As an informatics pharmacist, you will be a central figure in this lifecycle, acting as the bridge between clinical intent and technical implementation, ensuring that every line of code is traceable back to a vetted, approved standard of care.

19.2.2 The Policy Lifecycle: A Framework for Durable Standards

Effective policies are not created in a single meeting. They evolve through a structured, iterative lifecycle designed to ensure they are evidence-based, practical, and maintainable. As an informatics pharmacist, you will shepherd medication-related informatics policies through this entire process. Understanding each phase is essential for your success.

Visualizing the Policy Lifecycle

Masterclass Deep Dive: Executing Each Phase of the Policy Lifecycle

Let’s use a tangible example to walk through the lifecycle: Developing a policy for the use of “Smart Pumps” with dose error reduction software (DERS).

Phase 1: Drafting – From Vague Idea to Concrete Proposal

The need is identified: The hospital is implementing new infusion pumps with advanced safety software, but there’s no institutional standard for how they must be used.

Action Step	Informatics Pharmacist’s Responsibility
Literature Review & Evidence Gathering	You research best practices from organizations like the Institute for Safe Medication Practices (ISMP). You find clear evidence that requiring the use of DERS for all high-risk infusions significantly reduces harmful medication errors. You also gather internal data on past IV infusion errors.
Stakeholder Interviews	You meet with key stakeholders: the ICU nursing manager, the med-surg education specialist, the anesthesia technicians, and the clinical pharmacy manager. You ask them: “What are your biggest concerns about the new pumps? What parts of the workflow do we absolutely need to standardize?”
Drafting the Initial Policy	You synthesize all this information into a structured draft policy. You don’t start from scratch; you use the hospital’s standard policy template. The draft includes sections on Purpose, Scope (which units/meds it applies to), and specific procedural steps.

Phase 2: Review & Approval – Forging Consensus

Your draft is just a starting point. Now it must be vetted by the collective wisdom of the clinical staff through the formal governance process.

Action Step	Informatics Pharmacist’s Responsibility
Presentation to Pharmacy & Med Safety CAG	You present the draft policy to the P&M Safety CAG. You walk them through the evidence and the proposed procedures. A vigorous debate ensues. The ICU nurse points out a workflow conflict. The physician asks for an exception for emergencies. You facilitate this discussion.
Revision and Iteration	Based on the CAG’s feedback, you revise the policy. You add a clearly defined “emergency override” procedure and clarify the workflow for titratable drips. You bring the revised version back to the next CAG meeting.
Escalation for Final Approval	Once the P&M Safety CAG reaches consensus and formally approves the policy, it is submitted to the higher-level Clinical Governance Committee for final, official sign-off. Your Director of Pharmacy will likely present it, but you will be there as the subject matter expert to answer detailed questions.

Phase 3, 4, & 5: Implementation, Education, and Monitoring

With an approved policy, your work shifts from consensus-building to execution.

Phase	Action Step	Informatics Pharmacist’s Responsibility
Implementation	Drug Library Build	This is a massive informatics task. You work with your team to build the entire drug library for the smart pumps, ensuring every entry’s dosing limits, concentrations, and alerts directly reflect the approved policy. This is the technical enforcement of the standard.
	EHR Integration Build	You work with IT analysts to ensure the EHR can wirelessly transmit infusion orders to the pump and receive documentation back, a process called interoperability. You design the EHR alerts that will prompt nurses to use the DERS library.
Education	Develop Training Materials	You create tip sheets, newsletter articles, and presentation slides that explain not just *how* to use the pumps, but *why* the policy requires it. You frame it around patient safety.
	Train the Trainers	You conduct training sessions for the nursing education department and the pharmacy super-users, equipping them to teach their colleagues the new policy and workflow.
Monitoring & Maintenance	Audit & Compliance Tracking	After go-live, you use the pump’s data analytics software to track compliance rates with the DERS library. You create a monthly dashboard showing compliance by unit and identify areas that need re-education. You also track “good catches”—alerts that fired and prevented a potential error.
	Scheduled Policy Review	Hospital policies are not static. Your Smart Pump policy should have a scheduled review date (e.g., every 2 years). When that date arrives, you are responsible for bringing the policy—along with all your compliance and outcome data—back to the P&M Safety CAG to determine if any updates are needed.