JENNIFER COWEL, RN MHSAPATTON HEALTHCARE CONSULTING

TIPS FOR WRITING EFFECTIVE POLICIES

Reasons for Writing Policies and Procedures

Help make instructions and guidelines definite and help in the interpretation of policies and procedures

Provide quick settlement of misunderstandingsHelp reduce the range of individual decisions and

discourage management by exceptionCover recurring situations such that managers can begin

to make decisions that will be consistent every timeSet boundaries for jobs so that each employee knows in

advance what response he or she will get from others when taking actions, making decisions, and giving responses

Provide protection in the event of an audit or lawsuit

Do’s and Don’ts

Definitions

Basic Steps:

Identify policy/procedure topicsConduct researchEnsure current regulations are taken into considerationEnsure evidence based practices are taken into

consideration Write the first draft and getting it reviewed and revisedObtain approvals, publish, and distribute documentsIssue communications and conduct trainingAudit to ensure policy is being followedAnalyze documents for improvements and make revisionsAnd the cycle continues...from writing to revising to

writing to revisions...

SECTION HEADINGS

Header – Logo, title, number, dates, approvalsSubjectPurposeTable of ContentsPolicyDefinitionsProcedureDocumentationMonitoringReferencesApproval of policy and procedure

COMPONENTS OF A POLICY AND PROCEDURE

SUBJECTThe title of the Policy and Procedure PURPOSE OR DESCRIPTIONA summary or explanation describing the philosophy for the content of the document/process. TABLE OF CONTENTSFor lengthy (greater than 5 pages) Policy and Procedure, it is recommended to have a Table of Contents to

assist the user in navigating the content of the P&P. POLICYA policy statement identifies the non-negotiable elements of a process. The policy statement address what

is the “rule” rather than how to implement the “rule”. Example of a policy statement: Only Registered Nurses who have demonstrated competency may administer intravenous medications.

 DEFINITIONSMany processes have unique terms. In order that the end-user is able to understand the intended

language/concepts, it is recommended that pertinent terms be defined as the beginning of the P&P. PROCEDUREThe procedure section should provided the end-user with complete information required to complete the

task/process/function.

Writing a Procedure

The procedure should:Be developed with the end-user in mind.Be written to that the process can be easily followed by all

users.Designate all that is required in a process.Include a particular course of action intended to achieve a

result.Be a written set/sequence of defined steps and detailed

elements to produce a specified result.Be an evidenced based way to accomplish an objective.Be a written instruction for a task that outlines the

preferred and safest method of undertaking a task.Be “hyperlinked” with related policy and procedures.

Tips for Doing it Right

Address only one topic per policy. To close the gap between policy and practice, the first step is to write a well-crafted policy that

actually reflects the elements of care at the bedside. Writing policy calls for more than knowledge of the policy content – it requires an

understanding of how to communicate the information most effectively. The goals of an effective policy are different from the goals of the education associated with communicating the policy.

Keep it clear and brief Use clear, direct language – delete unnecessary words. Use short, declaratory sentences. Keep policies as brief as possible Use positive language whenever possible.

NO acronyms or abbreviations that are not defined. Use a consistent style and terminology. Make sure the title accurately reflects the topic. Test the policy – ask people to tell you what they think it says. Avoid “reinventing the wheel” – review sample policies before drafting a new

policy. Establish the minimum expectations surrounding a particular activity or action;

Tips for Doing it Right

Outline the responsibilities of the individuals involved; and,

Set minimum rules for documentation or communication (as applicable).

Policies communicate concepts, while procedures are a set of steps.

Procedures should be logically communicated, indicating what should be first, second, and third. Consider creating a flowchart of the process prior to converting it to policy format.

Before writing, determine essential messages, such as regulatory elements, what to do, safety aspects, and important documentation elements.

Tips for Doing it Right

Establish actions and “rules” to comply with regulatory requirements in the context of your organization. Consider the use of regulatory language, as it is a general guideline with flexibility on implementation Joint Commission CMS CDC AORN

Do not set expectations that cannot be met in a live patient setting, as policies and procedures should set only minimum expectations for care.

Tips for Doing it Right

Be cautious when copying policies from other organizations or policy templates. They often contain references to parallel processes not in place in your organization. Change references to other hospitals and procedures that do not apply at your organization.

Ask a “non-healthcare” person to review the final version of the policy for clarity. Does it pass the “essential messaging” test? What am I expected to do and not do?

What comes first, second, third? What should I watch our for?

Assessment guidelines, side effects, warning signs What do I do if . . . ?

When to call the physician or administration What do I document?

Documentation guidelines Where can I go for more information?

References Once the policy has been finalized, it must be communicated to clinicians.

Whether or not a policy is followed can have as much to do with the way it is communicated as the policy itself.

Questions:

Jennifer CowelJenCowel@PattonHC.com