Date of Award


Scholarly Projects

Projects: SPU Access Only

Degree Name

Doctor of Nursing Practice (DNP)



Faculty Chair

Bethany Rolfe Witham

Faculty Reader

April Morgenroth

Executive Summary

Executive Summary

Introduction: In 2016, 1.8 million uninsured and under-insured Americans utilized free clinics for their healthcare needs (National Association of Free & Charitable Clinics [NAFC], nd.). One common problem facing free and charitable clinics is a lack of written policies and procedures formalizing their operational processes (Ffrench-Constant, 2014). A coherent set of policies and procedures reduces practice variation, ensures regulatory compliance, and serves as a written resource for staff and volunteers to balance access with quality of care (Ffrench-Constant, 2014).

Practice Question: What is the most effective and cost-efficient way for The Free Clinic to obtain a set of policies and procedures to enhance operation practices in order to remain in service to its target population?

Purpose Statement: By providing customized policies and procedures, The Free Clinic will be able to provide consistently high-quality care, establish a foundation for clinic growth, and meet all applicable regulatory requirements.

Methodology: The QI project utilized The Star Model of Knowledge Transformation and focused on a Free Clinic in rural Washington State. The DNP student contacted various US charitable organizations to obtain free, unrestricted policy/procedure sets for evaluation, adaptation, and possible use in The Free Clinic. At the completion of the process, three polices were adapted/written to meet the needs of the Free Clinic.

Results/Outcomes: The DNP student adapted two policy/procedures obtained from other free clinics and wrote one original policy/procedure. Each was free, met quality improvement goals, and was congruent with The Free Clinic’s mission statement. The Fire Safety Response Plan was introduced at The Free Clinic as a model to be followed for ongoing quality improvement implementation.

Implications/Sustainability: Policy and procedure writing and review is an integral part of every healthcare delivery organization. Free, open-source templates are not currently available nor easily shared between organizations for various reasons. In order to maintain up-to-date and appropriate policies and procedures, a full-time staff member or volunteer with experience in writing these documents would need to do two things:

1. Review the clinic’s existing policies and procedures; investigate current state, federal and local regulations; review current evidence; and then update regularly.

2. Identify missing policies and procedures and write them “from scratch” as the organization grows and the needs of the target population shift.