Date of Award


Degree Name

Nursing (D.N.P.)


College of Nursing

First Advisor

Dr. Anne McKay

Second Advisor

Dr. Katherine Moran

Third Advisor

Dr. Tanya Rowerdink


Policies and procedures guide practice and the care of patients in every field of healthcare. Incorporating best practice evidence into clinical practice is a critical step towards providing safer patient care and improved patient outcomes. The challenge has been finding a way to incorporate best practice evidence into policies and procedures. Accordingly, an evidence-based project to answer the following clinical practice question was proposed: What is an evidence-based strategy for reviewing, updating, and disseminating policies and procedures for office staff at a cancer treatment organization? Through the use of Donabedian’s Model for Quality Improvement, student created tools, and an evidence-based algorithm, this project was designed to provide an efficient and sustainable system for review and revision of policies and procedures in a healthcare setting. The deliverables to the organization are the evidence-based policy and procedure review system toolkit and the results of a pilot the DNP student conducted to demonstrate the use of the toolkit. Included in the pilot results are a detailed time log providing the length of time required to complete the review, recommendations for revisions to policies and procedures utilizing current evidence from literature, a budget analysis, a report of the current state of the organization and how the toolkit will aid in overcoming identified barriers, and recommendations for sustainability. The deliverables include the following: 1) Successful dissemination of the toolkit use to the site manager; 2) increased percentage of policies and procedures meeting compliance requirements for specialty pharmacy accreditation from 3% to 40%; 3) a step-by-step instruction guide for reviewing literature and policies and procedures with the incorporation of best practice evidence; 4) a proposed policy for policy review, and 5) an accurate budget for organizational planning to sustain policy revisions in the future.

Additional Files

M. Stokes Powerpoint.pdf (640 kB)