Responsibility for
Policies and Procedures
DR. Mohamed Seyam PhD. PT.
Assistant Professor Of Physical Therapy
There are several good reasons to
develop and implement policies and
procedures:
✦ To meet the requirements of licensing or other agencies that may demand
them.
✦ To avoid the potential trap of relying on memory to assure consistency in
conducting business over time.
✦ To demonstrate thoughtful, thorough attention to the details of the business to
stakeholders.
✦ To serve as evidence during legal proceedings. Note: wording that suggests
absolutes like “always” should be avoided; use typically, usually, etc. instead.
✦ To reflect the compliance of an organization’s commitment to state and federal
laws.
Selected Policies and Procedures
Required by The Joint Commission
✦ Abuse:
Recognition, Reporting, and
Patient Care
✦ Age-Appropriate Care
✦ Confidentiality of Patient Information
✦ Consent
✦ Human Resources Management Plan
✦ Infant and Child Security
✦ Infection Control Surveillance
✦ Interpreter and Translation Services
✦ Medical Device Safety
✦ Medical Record Review
Policies and Procedures
✦ Medication Administration
✦ Multidisciplinary Progress Notes
✦ Patient, Procedure, and Site Verification
✦ Patient Rights and Grievances
✦ Pain Management
✦ Patient Care Planning
✦ Patient and Family Education
✦ Plan for Provision of Patient Care
✦ Universal/Standard Precautions
✦ Verbal and Telephone Orders
Basic Principles of
Policies and Procedures

To be more usable, the policies and
procedures manual for any health-care
organization must be:
✦ Current and relevant to contemporary
work.
✦ Exclude clinical guidelines and
protocols.
✦ Exclude entries that are simply
information sharing.
✦ Be consistent in format (e.g., worded as
do’s rather than as do not’s).
Emphasize expectations rather than
what is unacceptable.
✦ Be accessible and easily retrievable.
✦ Include a complete history of changes
made to the document.
✦ Include guidelines for writing,
revising, and reviewing the manual.
Policies


A policy is a broad statement of an
expectation that guides decisions about
actions to be taken in an organization.
Policies reflect the general rules that
govern organizational procedures.

NONSMOKING FACILITY.

NETWORK SECURITY.

BUSINESS RULES.

KEYS AND LOCKS.

INTERVIEW EXPENSES.
Procedures

A procedure describes a particular way of
accomplishing an action.

Nonsmoking Policy, a procedure may be:
The Chief of Physical Plant Services:
1. Posts and maintains nonsmoking signs at all
entrances and other appropriate locations.
2. Designates two outdoor smoking permitted
areas and posts smoking permitted signs.
3. Places appropriate receptacles in each
designated smoking permitted area.
4. Checks on the condition of the signs
and smoking areas biweekly.
5. Replaces or repairs signage or areas as
necessary within 24 hours.
6. Receives reports of incidents of
smoking in violation of the policy from
employees and guests.
7. Reports incidents of smoking violation
to the Assistant Vice President of
Operations within 24 hours.
Other Organizational
Documents

Policies and procedures should be
distinguished from the bylaws of a
health-care organization, clinical
guidelines, and protocols.
 Bylaws.
 Clinical
practice guidelines.
 Protocols