A policy is a statement set forth by the hospital which should house the overall guiding principle of a topic and function of the policy. It should be developed in a multidisciplinary manner often developed and guided by the medical and nursing director. Other specialties such as pharmacy, respiratory therapy, infection prevention should be included in order to tie in other hospital policies and get buy-in. The policy must also state who will be responsible for implementation, education and enforcement of the various processes. Policies are often written as a policy statement or document stating the overall purpose of the policy, some background of the policy and it should be summarized in an easy-to-read format. These documents should be signed and dated and should be reviewed and updated every 2-5 years depending on the nature of the policy.

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• Process

It is often said that everything we do is a process. The process of getting to work every morning, going grocery shopping etc. Processes are often defined by what value they can add for whoever will benefit from the process – the customer. The customer drives the reason or the value of the process. Processes can be large, small complex or very simple. If one were to use a dictionary type definition for process a process would be defined as a set or series of actions, changes, or functions resulting in a desired result, an output or a specific service. A process describes who is responsible for performing activities and, what activities areperformed. Processes frequently consists of multiple procedures; the procedures describe in a step-by-step manner how each activity within a process is carried out. A Process is designed to address the needs of the customer. The external customer in the case of procedure in neonatology will be the patient and the family ultimately, they wish for optimal, timely and evidence-based care as well as frequent updates and avoiding complications secondary to being premature. They wish to leave the hospital with a baby who did not have an IVH, on full feeds, intact intestines, no G-tube, growing well, with no BPD and on a good neurodevelopmental track. The Internal customers may be the hospital administration wanting to boast good outcomes and patient satisfaction data, it may be including timing of calling pediatric surgery for the expected delivery of a patient with gastroschisis and manage the baby based on surgery’s wishes. The customers, both internal and external based on their needs drive what will need to be addressed by the process. Processes can get very complex and will need to be divided into subprocesses. Dividing complex processes into sub processes can make it easier to identify where one needs to make improvements and track any changes. Only processes that are truly understood can be improved. A visual presentation of a process makes it often easier to understand a process that is why flowcharts and process maps are frequently used. When several processes are tied in together and influence each other they can be visualized in an integrated product map.

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• Procedure

A procedure is a list of steps and instructions on how to address details to each step needed to perform an activity in a process.