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Step 9: Document Changes in Policies and Standard Operating Procedures

As an agency achieves its Patient, Staff, and Environmental goals there will be a need to communicate, provide education, and enforce these changes through policies and standard operating procedures. This step is critical to maintaining change.

The policies and procedures should be documented in a manner that is consistent with both the Change Plan and with documentation for other similar issues that the agency must address. For example, health care systems generally have policies for a wide variety of clinical and nonclinical issues such as prohibiting clients to sell drugs to each other, banning drug use on the grounds, describing procedures for detoxifying patients, and monitoring appropriate documentation. Tobacco policies in addiction treatment settings should be equally clear and well documented, defining both the boundaries on tobacco-related behaviors and the consequences if these boundaries are violated.




Task 1. Document policies and procedures.

These are needed for Patient, Staff, and Environment Goals. The agency’s expectations of employees, clients, and visitors should be clearly documented. Ensuring that these changes occur across the board where appropriate is often the charge of a work group on policies and procedures, which drafts language and recommends specific changes to the Tobacco Leadership Group.

Task 2. Integrate new policies and procedures in staff training and patient education.

Change takes time to become a natural and expected part of organizational culture. A frequent error on the part of organizations when they institute major changes is to train and publicize the change intensively at one point in time, but fail to provide the reinforcement needed to integrate the change. In so doing, they neglect existing employees, some of whom may need time to overcome their initial resistance, as well as new employees entering the agency.

Task 3. Integrate new policies and procedures in performance review.

If expectations of employees regarding the agency’s new antismoking policies are formalized in staff job descriptions, it is fair and logical to consider how well they have performed these responsibilities. This will help ensure that each staff member is incorporating the new policy into daily routine practice. Supervisors should be prepared to provide feedback to staff on their performance.

Task 4. Communicate new policies externally to increase impact and understanding.

There are many reasons to communicate your agency’s commitment to addressing tobacco addiction externally as well as internally. Some of the most important ones are:
  • To anticipate and proactively address problems that may arise with neighbors,
  • To bring in partners who can reinforce and broaden your agency’s efforts,
  • To coordinate with sources of referrals to your agency and help your clients stay tobacco-free after completing treatment, and
  • To model and encourage healthy change in health care providers and businesses.

Anticipate and proactively address problems that may arise with neighbors. Bring in partners who can reinforce and broaden your agency’s efforts.