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UPDATED SEPTEMBER 2022 BOCATC.ORG/POLICY BOC Guiding Principles for AT Policy and Procedure Development BOC GUIDING PRINCIPLES FOR AT POLICY AND PROCEDURE DEVELOPMENT BOCATC.ORG 2 Table of Contents DISCLAIMER 3 INTRODUCTION 4 POLICY WORKSHEETS 6 7 Employee Safety 6 Facility Management 7 Patient Safety 9 PrivacyConfidentiality 10 Risk Management 11 SAMPLE POLICIES AND PROCEDURES 13 7 Crisis Management 13 Crisis Communication Procedures 17 Disposal of Medical Sharps 19 Emergency Action Plan 21 Exertional Heat Illness 23 Electrical or Facility Safety 27 Health Records 29 Infection Prevention and Controls 31 Lightning Safety 35 APPENDIX I : TEMPLATE FOR POLICY AND PROCEDURE DOCUMENT 37 APPENDIX II: CHECKLIST FOR DEVELOPMENT AND REVIEW OF INDIVIDUAL POLICIES AND PROCEDURES 38 APPENDIX III: SAMPLE FORMS FOR EMERGENCY ACTION PLANS 42 BOC GUIDING PRINCIPLES FOR AT POLICY AND PROCEDURE DEVELOPMENT BOCATC.ORG 3 The materials and information provided in the “Board of Certification, Inc. (BOC) Guiding Principles for AT Policy and Procedure Development” are educational in nature. “BOC Guiding Principles for AT Policy and Procedure Development” is published as a resource for Athletic Trainers (ATs) and members of the public and is intended solely for personal use/ reference in the manner described herein. The BOC has taken reasonable efforts to ensure that all materials included in “BOC Guiding Principles for AT Policy and Procedure Development” are accurate and consistent with standards of good practice in the general athletic training industry. As research and practice advance, however, standards may change. For this reason, it is recommended that ATs and the public evaluate the applicability of any materials included in “BOC Guiding Principles for AT Policy and Procedure Development” in light of particular situations and changing standards. By accessing “BOC Guiding Principles for AT Policy and Procedure Development,” individuals agree to use the document appropriately and within applicable state laws regarding athletic training licensure and/or regulation. In no event shall the BOC, its directors, officers or employees be held liable for any losses, injury, damages or any other consequences resulting from, or arising in connection with, the use or reliance on any materials provided in or accessed via “BOC Guiding Principles for AT Policy and Procedure Development.” By accessing “BOC Guiding Principles for AT Policy and Procedure Development,” all individuals who make use of the document agree to indemnify, defend and hold harmless the BOC, its directors, officers or employees, from and against any and all losses, costs, expenses, claims, damages and liabilities related to or associated with the use of “BOC Guiding Principles for AT Policy and Procedure Development,” including but not limited to any and all losses, costs, expenses, claims, damages and liabilities arising from or related to the improper use of “BOC Guiding Principles for AT Policy and Procedure Development.” By accessing “BOC Guiding Principles for AT Policy and Procedure Development,” all individuals who make use of the document agree to abide by applicable state laws and BOC standards, rules and regulations regarding the lawful practice of athletic training. Disclaimer BOC GUIDING PRINCIPLES FOR AT POLICY AND PROCEDURE DEVELOPMENT BOCATC.ORG 4 BACKGROUND The “BOC Guiding Principles for Policy and Procedures Development” was created by the Facility Standards Work Group in 2016. Their goal was to develop educational materials to assist ATs and other appropriate individuals in the development of policies and procedures for the delivery of health care in their organization. The 2016 work group included: Jerry Diehl (Committee Chair) Christopher Dean, ATC Doug Killgore, CMAA David Klossner, Ph. D, AT Ret. Brian Michelotti, BA Mark Stoessner, MA, AT, ATC Ericka P. Zimmerman, EdD, LAT, ATC, CES, PES The document provides a template to guide the development of policies and procedures in a manner that will be clear to all the appropriate individuals. In addition, the template provides a record-keeping function to demonstrate that training and retraining are a part of policy implementation. This is a critical part of organizational risk management. Sample policies and procedures are also included to help guide the reader in the development of policies and procedures specific to their organization. The following resources will help gauge your athletic training facility’s compliance with applicable state, federal and oversight agency regulations, as well as best practices. POLICIES AND PROCEDURES Policies and procedures are a critical component of any risk management plan, providing individuals with instructions to carry out the organization’s expectations. When written properly, clear expectations (policies) and instructions (procedures) allow for a policy to be implemented and provide standardization in daily operational activities. Policies and procedures provide clarity when dealing with issues and activities critical to health and safety, legal liabilities and regulatory requirements. Organization leaders use policies and procedures to help communicate desired outcomes to employees and other individuals; further, they help clarify roles and responsibilities within the organization. Policies should set the foundation for the delivery of safe and effective care. ADVANTAGES OF POLICIES AND PROCEDURES Provide Structure to the Program - Well- written policies and procedures provide structure to any organization, no matter what size. By creating policies and procedures, organizations “know what the rules are” and how to measure compliance. Provide Guidelines - They communicate the expectations of the organization, provide a guide for action, and help employees and supervisors to understand their jobs and responsibilities. A policy and procedure manual also helps employees and supervisors know how to respond to issues that might arise during the course of business. Promote Consistency - Policies and procedures provide the framework within which an organization operates. They define what the organization does and how. Clear policies and procedures support effective decision- making and delegation of responsibility as they provide guidelines on what people can and cannot do, what decisions they can make and what activities are appropriate. A clear policy framework results in fewer misunderstandings or debates about what to do in particular situations, meaning there will be transparency and consistency in the way the organization operates and makes decisions. Adherence to Laws and Regulations - With the rapid pace of new and updated laws, organizations may struggle to adhere to and communicate ever-changing regulations and best practices. A policies and procedures document, when kept current, helps providers ensure compliance with all laws and simplifies the process of communicating change organization-wide. Introduction BOC GUIDING PRINCIPLES FOR AT POLICY AND PROCEDURE DEVELOPMENT BOCATC.ORG 5 Introduction Risk Management - Policies and procedures must comply with local, state and federal laws. For every new law or regulation, new or updated policies must be created and disseminated to staff. There are regularly changing provisions within the federal health care requirements, state laws and regulations. This makes it difficult to ensure that proper policies are not only created, but are efficiently communicated to the employees and all the appropriate individuals. It is difficult simply keeping up with every new law or regulation update. Ensuring policies and procedures are effectively rolled out to employees and all the appropriate individuals are just as complicated. In addition, policies and procedures should be reviewed and approved annually. The previous year’s copy should then be kept as a part of the overall risk management plan. SUMMARY The process of developing and implementing policies and procedures is a practice that an organization will work on over a period of time in order to comply with legal requirements. Policies and procedures connect an organization’s vision and goals to internal operations. They are internal controls and are vital to accountability within the organization’s structure. Policies create an expectation or guide for an action within the organization, while procedures include step-by-step directions to carry out each policy. Blended together, policies and procedures provide a road map for an organization’s workforce to follow. BIBLIOGRAPHY Adams WM, Casa DJ, Drezner JA. Sport Safety Policy Changes: Saving Lives and Protecting Athletes. Journal of Athletic Training. 2016;51(4):358-360. Buchbinder SB, Shanks NH. Introduction to Healthcare Management, 2nd Ed. Burlington, MA: Jones & Bartlett Learning; 2012. Harrelson GL, Garner G, Winterstein AP. Administration Tropics in Athletic Training Concepts to Practice. Thorofare, NJ: Slack, Inc.; 2009. Pagnotta KD, Mazerolle SM, Pitney WA. Burton LJ, Casa DJ. Implementing Health and Safety Policy Changes at the High School Level From a Leadership Perspective. Journal of Athletic Training. 2016;51(4):291-302. Pozgar, GD. Legal Aspects of Healthcare Administration, 12th Ed. Burlington, MA: Jones & Bartlett Learning; 2016. Ray R, Konin J. Management Strategies in Athletic Training. Champaign, IL: Human Kinetics; 2011. Zimmerman, EP. Checklist for Development and Review of Individual Policies and Procedures. Omaha, NE: Board of Certification for the Athletic Trainer; 2016. Zimmerman EP. Litmus Testing Your Program’s Policies & Procedures. CAATE Accreditation Conference. October 17, 2015. BOC GUIDING PRINCIPLES FOR AT POLICY AND PROCEDURE DEVELOPMENT BOCATC.ORG 6 As you prepare to develop policies and procedures, it’s important to consider a few questions about your athletic training facility and athletic health care program. Following are worksheets that will help you decide if your organization needs policies and procedures such as employee safety, facility management, patient safety, privacy/confidentiality and risk management. Policy Worksheets - Employee Safety 1.Are all employees required to have bloodborne pathogen training annually? Yes No If yes, the program should: • Have a policy for training and maintaining records of employee training. • Check for any additional requirements by the state or other governing bodies (e.g., National Collegiate Ath- letic Association (NCAA)). 2.Are all employees trained in infection prevention and control? Yes No If yes, the program should: • Have a policy for training and maintaining records of employee training. • Have personal protective equipment available (e.g., gloves, face masks) • Have appropriate disinfectant materials available. 3.Do you provide first aid care that involves blood? Yes No If yes, the program should: • Have a policy on bloodborne pathogen training for all staff. • Have a policy on disposal of medical sharps. • Have personal protective equipment available (e.g., gloves, face masks). • Provide appropriate waste disposal containers. 4.Do you use scalpels, needles or other such tools (e.g. needles to drain blisters)? Yes No If yes, the program should: • Have a policy on bloodborne pathogen training for all staff. • Have a policy on disposal of medical sharps. • Have personal protective equipment available (e.g., gloves, face masks). • Provide medical sharps containers. 5.Do you have a dress code? For ATs, for patients/student-athletes? Yes No If yes, refer to:Reference: www.osha.gov to ensure compliance with regulations 6.Do you use a golf cart or other motorized vehicle to assist the athletic training program? Yes No If yes, the program should: • Have a policy on who can operate vehicle. • Have a policy on maintenance of the vehicle. • Check organization’s insurance coverage for use of the vehicle by employees/non-employees. 7.Do you have an active-shooter policy? Yes No If yes, the program should: • Ensure that training in the policy is documented. BOC GUIDING PRINCIPLES FOR AT POLICY AND PROCEDURE DEVELOPMENT BOCATC.ORG 7 Policy Worksheets - Facility Management 1.Are there any full walls, pillars or other obstructions in the athletic training facility? Yes No If yes, the program should: • Have a policy requiring staff on the floor when patients are in obstructed view areas. 2.Do you have paper, plastic, wood or any other flammable materials (e.g., chlorine, oxygen) in the athletic training facility? Yes No If yes, the program should: If yes, refer to: • Have a policy on fire safety including training. • Have a fire extinguisher in or near the facility. Reference: www.osha.gov 3.Do you have oxygen available for emergency use? Yes No If yes, the program should: If yes, refer to: • Have a policy for annual training on use, storage, handling and transportation of oxygen. Reference: www.osha.gov 4.Do you have electrical outlets located near water sources? Yes No If yes, the program should: • Have a policy for annual ground fault circuit interrupter (GFI) inspection and maintenance of records of inspection. • Have a policy on unplugging devices when not in use. 5.Do you operate a whirlpool/pool in the athletic training facility? Yes No If yes, the program should: • Have a policy for annual GFI inspection. • Have a cleaning/disinfecting policy. • Have a policy for supervision when whirlpools are in use. 6.Do you have rehabilitation equipment in the athletic training facility? Yes No If yes, the program should: • Have a policy on inspection, cleaning, maintenance and repair. • Have a policy of lock out/tag-out to prevent use of broken equipment. 7.Do you have any modalities in the athletic training facility? Yes No If yes, the program should: If yes, refer to: • Have a policy for annual maintenance and calibration recorded and maintenance of inspection records. • Have a policy for regular GFI inspection. Reference: www.asrt.org/main/standards-regulations 8.Is your facility inspected annually? Yes No If yes, the program should: If yes, refer to: • Have a policy to ensure compliance with all local and state fire and electrical codes. • Ensure compliance with applicable regulations regarding access. Reference: www.ada.gov BOC GUIDING PRINCIPLES FOR AT POLICY AND PROCEDURE DEVELOPMENT BOCATC.ORG 8 Policy Worksheets - Facility Management 9.Do you have an automated external defibrillator (AED)? Yes No If yes, the program should: If yes, refer to: • Ensure the device is publicly accessible. • Have a policy on AED training. • Have a policy for inspection and testing of the AED. • Ensure that all emergency action plans include location of and use of AED. Reference: www.nata.org/sites/default/files/automatedexternaldefibrillators.pdf 10.Do you have carpeted areas in the athletic training facility? Yes No If yes, the program should: • Have a policy on cleaning and disinfection of surfaces in the athletic training facility. 11.Does the custodial staff clean the athletic training facility? Yes No If yes, the program should: If yes, refer to: • Have a policy for bloodborne pathogen training of all staff. • Have a policy on proper disposal of contaminated materials. • Have a properly marked receptacle for contaminated materials. • Ensure that personal protective equipment is available. References: www.natajournals.org/doi/pdf/10.4085/1062-6050-45.4.411 www.nata.org/sites/default/files/mrsa.pdf 12.Do you use towels, pillowcases, etc. in the athletic training facility? Yes No If yes, the program should: • Have a policy on changing out/washing linens. • Have a policy for washing laundry/linens/towels contaminated with blood/body fluids. BOC GUIDING PRINCIPLES FOR AT POLICY AND PROCEDURE DEVELOPMENT BOCATC.ORG 9 Policy Worksheets - Patient Safety 1.Do you fill coolers with ice and water or sports drinks? Yes No If yes, the program should: • Follow local health department regulations/requirements. • Have a policy for cleaning, drying, storing and inspection of coolers. • Have a policy for cleaning, inspection, maintenance of hoses and hardware (PVC pipes, etc.). 2.Do you use any non-cooler watering systems (e.g., Hydration Station TM , Waterboy © )? Yes No If yes, the program should: • Have a policy for cleaning, inspection, maintenance of hoses and hardware (PVC pipes, etc.). 3.Do you clean treatment areas between patients? Yes No If yes, the program should: If yes, refer to: • Have a policy for bloodborne pathogen and infectious disease education and training. • Have a policy for sanitation of the athletic training facility. • Have a hand hygiene policy. References: www.natajournals.org/doi/pdf/10.4085/1062-6050-45.4.411 www.nata.org/sites/default/files/mrsa.pdf www.cdc.gov/handhygiene/index.html 4.Do you have patients or staff members who need to use asthma inhalers, EpiPens® or other emergency medications? Yes No If yes, the program should: If yes, refer to: • Have a policy on disposal of expired medications. • Have a policy on storing medications for travel or outdoor use (EpiPen® in the sun). • Have a policy on use and storage of prescription emergency medication including any requirement for training. Reference: www.nata.org/sites/default/files/mgmtofathletewithtype1diabetesmellitus.pdfNext >