Responsibility for Policies
and Procedures
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
✦ 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.
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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.
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Bylaws.
Clinical practice guidelines.
Protocols