Policies and Procedures
School health service policies and procedures are essential for ensuring the well-being of students and staff within educational settings. These policies and procedures typically cover a wide range of areas related to health promotion, illness prevention, emergency response, and the management of health-related issues.
Policies
A policy is a guide for decision making within an organization that is a rule for action. Policies are typically developed and adopted by the local school board after being systematically reviewed by a team.
Policies should be based on federal, state, local laws, or rules and regulations; on standards established by state agencies such as the Minnesota Department of Education, Minnesota Department of Health, the Board of Nursing, or the Board of Teaching; on standards set by professional organizations such as the American Nurses Association (ANA), National Association of School Nurses (NASN), American Academy of Pediatrics, American School Health Association, etc. Codes of ethical conduct for the various professions are also considered when developing policies.
In Minnesota, many schools adopt or modify policies developed by the Minnesota School Board Association. Each district will have a unique process for developing, reviewing, approving, and sharing policies. Some schools maintain policies in paper manuals, but many have moved to on-line or web-based approach. School health staff should understand the policies that impact nursing and health services for student and become familiar with the school’s process and timelines for revising policies.
Procedures
A procedure is a sequence of steps that should be followed to implement policies. Sometimes procedures are also referred to as protocols. School health and/or nursing procedures are best written by expert program staff such as the professional nurse (LSN/RN). Whereas policies are broad, procedures are specific and detailed but should align with school policy (when a policy exists).
Procedures should clearly outline:
- who can or will do the task,
- when the task will be completed,
- where it will take place,
- what steps are expected,
- how to manage uncertainties or problems,
- how it will be documented, and
- any other information that is key to the safe and consistent completion.
Procedures should be dated when issued or reviewed or revised. Review / revision is recommended at least every two years. Schools may have paper manuals or on-line web based procedure manuals. Written procedures that are based on evidence or best practices help to improve quality, safety and consistency of health services provided to students. It will help school staff orient and set expectations for new staff or substitute staff and avoid “we always have done it this way”.
It is the responsibility of the school nurse to “provide regular critical review and evaluation of policies, procedures, and guidelines to improve the quality of health care and the delivery of school health services.” Standard 15, Quality of Practice, School Nursing Scope and Standards of Practice 4th Ed.
Clinical Laboratory Improvement Act (CLIA)
CLIA is a federal law that is managed, overseen and enforced by the Minnesota Department of Health: CLIA.
- All U.S. facilities or sites that test human specimens for health assessment or to diagnose, prevent, or treat disease must have a CLIA certificate and follow the CLIA regulations. This includes schools.
- The CLIA requirements are based on the complexity of the test and the type of laboratory where the testing is performed.
- Tests are classified by the FDA as either high complexity, moderate complexity, or waived.
- Waived tests, such as those done in schools, are deemed safe and reliable outside of a lab. Examples of waived tests in schools include but are not limited to blood glucose monitoring devices, testing for urine ketones, influenza or COVID-19 tests. The Food and Drug Administration (FDA) provides a complete list of waived tests.
- Schools need a CLIA Certificate of Waiver to be in compliance with federal statute when performing tests such a blood glucose, urine for ketones, COVID-19 testing, etc. The Waiver is renewed every 2 years, after paying the certificate fee. Contact MDH if you are unsure if your school has a waiver or to make changes to an existing waiver at health.clia@state.mn.us.
- When performing waived tests, an agency is subject to only 2 CLIA regulations; follow all manufacturer’s instructions for use and report all COVID-19 test results to the appropriate health authorities (MDH). Schools with a Waiver are not subject to routine inspection but may be surveyed in response to a complaint.
Frequently Asked Questions
Can I get a waiver for the district or does each school/location need a separate waiver?
- Generally, you will need a one waiver for your district, charter school or private school.
What if the student is independent in testing. Do we need a CLIA waiver?
- If the student is independent and the nurse or staff member is only providing stand by guidance, you would not need a Certificate of Wavier.
- If total or partial assistance is needed, such as interpreting results, then you need a Certificate of Waiver.
What if the student is bringing or using their own equipment verses school owned equipment. Do we need a Waiver?
- It doesn’t matter who owns the equipment.
- If staff are doing/assisting with the testing in a school/ school location, you will need a Certificate of Waiver.
If we have a continuous glucose monitor and alter insulin pump, would we still need this in case we have a device malfunction and need to manually test I would assume?
- Yes, if you need to perform the test for the client you need a CLIA certificate of Waiver to do so.
How do we find out if the District / School already has a CLIA waiver?
- Email health.clia@state.mn.us
What does it mean to follow the manufacturer’s instructions for performing the test?
- To follow the manufacturer’s instructions for performing the test means to follow all of the instructions in the package insert from “intended use” to “limitations of the procedure.”
- The manufacturer’s instructions can be found in the package insert for each test. It is good laboratory practice and important to read the entire package insert before you begin testing.
- Be sure the package insert is current for the test system in use, the correct specimen type is used, the proper reagents (testing solutions) are added in the correct order, and the test is performed according to the step-by-step procedure outlined in the package insert.
Who is listed as the “Director of Laboratory” for a school?
- Generally, this would be the Licensed School Nurse or Registered Nurse for the school or district. One person can be listed for the entire district, even if there are other school health staff in the various building performing the waived tests. Question should be directed to: health.clia@state.mn.us
Resources
How to Apply for a CLIA Certificate the completed CMS-116 form (pdf) should be sent to MDH at health.clia@state.mn.us
Self-assessment Checklist (pdf)
Ready? Set? Test! Booklet (pdf)
Communication of Policies and Procedures
Each school district has a process for communicating policy development and approval to school staff, families, and the community. School health policy and procedures should be available for review by any interested parent/legal guardian or student. It is important to communicate and share school health related policies and procedures in manner that is understandable to students and families.