Developing Policies and Protocols in the Age of Evidence-Based Practice

Prior to evidence-based practice, policies and procedures were reviewed annually or even triennially to ensure that they reflected current practice and demonstrated adherence to regulatory standards. With the publication of the Institute of Medicine report, a shift to operationalization of best evidence practices, formal statements, and frameworks for care has gained increased importance. Processes for policy and protocol development and revision are now based on the inclusion of best evidence, clinician expertise, and patient values or preference. Policies and protocols are now updated when new evidence justifies a revision and are designed to share the most recent evidence and facilitate staff adherence to new practices. This article describes the essential practices for policy and protocol development, including leadership support, team commitment, identification of current resources, recognition of current practices, development of the policy and protocol to logically flow with nursing practices, effective dissemination methods, and evaluation and sustainability practices.