Tips for Policies and Procedures

Lydia Lehnertz, WI AHEC CHIP Intern - Buffalo County & Alyssa Weinrich, WI AHEC CHIP Intern – Pepin

County

Introduction• Assigned to project from Wisconsin Area Health

Education Center (AHEC) Community Health Internship Program (CHIP) within Pepin and Buffalo Counties.

• Goal to update policy and procedure manual to a standardized electronic format

• Created PowerPoint to help others find an effective way to update, maintain and create policies and procedures in an electronic format

Contents

• Table of Contents• Guide to Hyperlinking• Standardized Template• Policy Review• Revision Log• Archiving Documents• Tips for Accreditation

Standardized Table of Contents

Useful components of electronic table of contents:

1) Subheadings organized in logical way

2) Columns for dates effective, reviewed, and revised

3) Policies hyperlinked from title listed in table of contents

Example Table of Contents

  Effective Revised Reviewed

A. Administrative Policy 01/05/10 06/15/12B. Background Checks for Employees 12/03/03 6/29/2012C. Accident/Injury (employee or client) 10/01/03 7/1/2012D. Job Descriptions 07/01/03 06/28/12

2. Adult Health

A. Blood Pressure Screening of Adults 11/10/03 06/26/12B. Wisconsin Well Women Program 05/31/07 06/20/12

3. Communicable Disease A. Communicable Disease Investigation and Control 12/19/07 06/25/12B. Infection Control/Bloodborne Pathogen Exposure Control Plan 07/16/09 6/22/12

4. Emergency Preparedness

A. Response to Public Health Emergencies 05/31/08 07/03/125. Environmental Health

A. Home Visitation: Elimination of Second Hand Smoke Exposure 09/05/08 06/28/12B. Recreational Water: Restricted Use/Closure 08/01/03 07/01/12

1. Administration

Pepin County Public Health Department Policy & Procedure Manual

Policy & Procedure

Guide to Hyperlinking

2 different options:

1) You can hyperlink existing text

Ex: A hyperlink for policy xyz…

2) You can select location where you want hyperlink after text

Ex: A hyperlink for policy xyz can be found here: s://publichealth/policy/xyz

How to Hyperlink Existing Text

• Highlight words you want to hyperlink• Right click your mouse• From dropdown select hyperlink• On left hand side select “existing file or webpage”• Select location of file• Click “ok”

How to Hyperlink Following Text• Place curser where you want to hyperlink• Right click your mouse• From dropdown select hyperlink• On left hand side select “existing file or webpage”• Select location of file• Click “ok”

How to Open a Hyperlink

• Right click the text you hyperlinked• Select “open hyperlink” from dropdown menu• File should open automatically in new window

Standardized Template for Policies and Procedures• Found many different methods for structuring policy

and procedure manual• Decided to use format that included purpose

statement, policy, procedure, references/legal authority

• Could possibly add other components such as: responsible staff, definitions, supplies needed, related policies

• Key to keep the policy and procedure as SIMPLE as possible

Example Policy Template

POLICY TITLE: EFFECTIVE DATE: DATE REVIEWED/REVISED: AUTHORIZED BY:

PURPOSE STATEMENT: POLICY: PROCEDURE: REFERENCES/LEGAL AUTHORITY:

Policy Review

• There is no set guideline as to how often policies need to be reviewed; however, they need to be kept current

• Local policies at each health department give the specific details within their policies (ex: create and/or execute a policy on policy revisions)

Tips for Keeping Policies Current

• Use a table of contents with columns for effective date, date reviewed/revised

• Develop a sign-off sheet to be kept in a central location

• Create a revision log which allows you to make note of future changes needed to policies

• Find an effective method for keeping revisions current (ex: policy review at staff meetings, individual accountability)

Example Revision LogDate Description of Change Page # Revision made by Rational

Record of Changes Template

Archiving Documents

• Health Departments should have their own policy on policy retention

• One option for organizing policies is to create “archived policies” folder within electronic policy and procedure manual

• Organize based off method that works best for your health department

Tips for Accreditation

• Policies and procedures cannot be drafts• Must be in electronic format• Must have documentation for each standard and

measure within Public Health Accreditation Board Standards and Measures

Helpful Resources for Accreditation

• National Association of City and County Health Officials (NACCHO)

- Contains toolbox with examples of each domain• Public Health Accreditation Board (PHAB)

- Contains structure and guidelines for accreditation

process• Public Health Accreditation Wisconsin (PHAW)

- Private webpage available upon request from

regional office

PHAB Website

• Found to be very helpful throughout this process• Contains standards and measures necessary for

becoming accreditation • Each measure requires documentation to prove

compliance • Next slide outlines measures that may require a

policy and procedure

Policies and Procedures Necessary for Accreditation in 2012 Measure Description

2.2.1A Two examples of written protocols for containment/mitigation of health problems and hazard

2.3.1A Outline how the health dept. maintains 24/7 access to support services in emergencies. May be in the All Hazards Emergency Operations Plan or separate.

2.3.2A Policies and procedure that assure 24/7 laboratory coverage may be in the all Hazards Emergency Operations Plan or separate protocols for the handling and the submission of specimens.

2.3.3A Identify support personnel who will be called on to provide surge capacity

5.4.2A Written communication protocols that provides a means for the department to contact health care providers, response partners, the media, and others 24/7. Must include contact information and be updated at least annually.

6.3.1A Written procedures for communications, updated biennially that include: 1) Disseminating accurate, timely, and appropriate information for different audiences 2) informing and/or coordinating with community partners for the communication of targeted and unified public health messages 3) Maintaining a current contact list of media and key stakeholders 4) Designating a staff position as the public information officer 5) Describing responsibilities and expectations for positions interacting with news media and the public

6.3.2A Protocol for scheduling inspections of regulated entities

Policies and Procedures for Accreditation ContinuedMeasure Description

6.3.5A Must provide a communication protocol for interagency notifications. The health department must provide a protocol for notifying the public when required.

9.1.1A Document leadership’s engagement in setting a policy for and/or establishing a performance management system for department

10.2.1A Human subjects research protection policy. If never involved with research that involves human subjects, a policy stating that fact

11.1.1A Must provide written operational policies in hard copy or electronic format. Reports of review at least every 5 years or proof of regular updating process. Description of methods for staff access to policies.

11.1.2A Maintain written policies regarding confidentiality, including applicable HIPPA requirements.

11.1.3A Policy and procedure for the development of interventions and materials that are culturally and linguistically appropriate for the population it serves in its jurisdiction.

11.1.4A Human resource policy and procedure manual or individual policies. The policies and procedures must address the following: Personnel recruitment, selection, and appointment; equal opportunity employment; salary structure; hours of work; benefits package; performance evaluation process and individualized development plans; problem solving and complaint handling, including sexual harassment. Written description of how staff access human resources policies and procedures.

Conclusion

• Keeping policies current is easier said than done• Find a method that works best for your health

department• Best of luck and remember to keep it simple!