ELABORATING
POLICY AND PROCEDURE MANUALS
for
Community–based Social Services
for Persons with Disabilities
Discussion paper
Handicap International,
July 2007
Handicap International - SEE
Manuals of policies and procedures for social services/2007/
This paper is part of a wider documentation produced by Handicap International in
South East Europe, for social service providers in the disability field.
For comments and further details please contact Handicap International:
SSEO program
1 Velisava Vulovica,
Belgrade, Serbia
Tel./fax: +381 11 3066 398
E-mail: diana.chiriacescu@hi-see.org
or
lisa.adams@hi-see.org
Social Services for Equal Opportunities (SSEO) is a
program developed by
Handicap International
in South East Europe
Note:
This paper is a draft of Handicap International (Regional Office for South East Europe) and is for
internal use only. It is not to be circulated without permission from Handicap International.
Produced by the
Regional Office of
Handicap International f
or South East Europe
Funded by
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Please note that this guideline represents only a discussion paper of Handicap International
(Regional Office for South East Europe) with regards to this type of internal document. It is a
practice-based tool, addressed mainly to small community-based social services.
It is recommended to each provider who is interested in this kind of instrument
to adapt it to its profile and particularities.
In the countries in which the national legislation includes specific requirements regarding the
manuals of policies and procedures for social services, its elaboration will be strictly related with
these legal requirements.
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TABLE OF CONTENTS
Part 1 – The purpose and roles of policy and procedures manuals in social service delivery
What are the policy and procedures manuals?
Why should we write them?
What are the benefits of writing policies and procedures in a service?
Part 2 – The content and format of the policy and procedures manual – different possibilities and
choices
A. “Standard” manuals of policies and procedures
Which is the difference between “policies” and “procedures”?
How can we select the appropriate policies for our service?
How many policy areas should we include in the manual?
How to organize and update the content of the manual?
 The policy layout
 The procedure layout
 The loose leaf folder and the numbering system
 The manual review and the amendments.
The “employee handbook”
Recommendations
B. The manual of policies and procedures as part of the overall “organisational project”
What is an organisational project?
Why is this document an interesting reference for South East Europe?
Part 3 – Responsibilities regarding the overall manual of policies and procedures
Who elaborates it?
Who revises it?
Who is in charge with the copy and distribution of the manual to new staff
members?
Who is in charge to explain the manual to the users?
ANNEX 1 (updated in December 2009) – An example of a policy formulation from Montenegro
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Part 1 – The purpose and role of the policy and procedures manual
What are the policy and procedures manuals?
Why should we write them?
What are the benefits of writing policies and procedures in a service?
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What is a “policy and procedures manual”?
The policy and procedures manual is the governing documentation that defines the profile of a service, as
well as the way in which all specific activities should be done in the respective service. It is an internal
regulatory instrument that contributes to a transparent, accountable and qualitative service delivery.
Each organization has its own system of internal rules and procedures. Even when they are not written,
these rules exist. But when they are not written, it is very difficult for the organization to prove its
accountability, to review these rules and to evaluate their efficiency. Sometimes, organizations can become
inconsistent, conflictual or inefficient because of the lack of written policies and procedures.
The policy and procedures manual helps the organization to make visible (for users, staff members or
various partners) the agreed policies and practices of the respective service. The manual is supposed to be
regularly updated, reflecting the changes and the evolution of the organisation or the service.
The manual is usually conceived on two-level structure:
(a) the overall set of policies that is relevant for the respective service and
(b) the implementation procedures which are needed for reaching the policy goals and
objectives.
Policies are built on what you believe to be the ‘heart and soul’ of quality in your organisation (the so called
“key determinants” of quality1). They tell us what should be done in the service.
In other words, a policy is a high level plan that defines the general values, goals, and directions of a
service. The policies require the validation of the general assembly of the organization, or of the
board of directors.
The procedures describe a logical sequence of activities or processes that are to be followed in order to reach
the goals and directives of a related policy.
They are in fact step by step guidance that shows us how to complete a task or function in a correct
and consistent manner. Procedures can be produced in the form of flowcharts, checklists, or detailed
written steps of the process. Procedure documents are less formal, have a more practical role, and
the content usually requires only the approval of the service’s manager.
For each agreed policy we have to write the related procedures. Policies tell us what should be done;
procedures describe how to do the respective task or how to reach the respective goals.
Why should we write a manual of policies and procedures in our service?
1. First, a manual is an internal regulatory instrument which presents and explains the mandatory
procedures developed for each department of the social service, in order to comply with the
minimal quality standards in the respective field of action. The manual regulates the overall activity
of the service and creates the premises for providing the activity at the same level of high quality, on
long term. It makes possible as well the control and the review of practices.
1
Dyson.M., “How and when to write policies and procedures”, ACROD, Queensland, 1999
(http://www.safework.sa.gov.au/contentPages/docs/labrWritingPolicy.pdf)
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2. The manual of policies and procedures gives also the overall framework for action in the respective
service, which offers the staff a background for the daily work, at the required level of quality.
3. The manual can be seen as well as a “business card” of the social service. It can be used (in an
abbreviated form eventually) as an informative material for the general public, for users and
authorities representatives etc.
4. It is also a tool for improving efficiency in the work. Once the rules and procedures are settled and
written, people in the organisation don’t have to keep on discussing and re-discussing the same
issues every time they arise. The agreed decision can be applied to many similar cases.
5. The manual of policies and procedures is also strictly related with the national quality standards or
other legal requirements at national level. It is a tool that ensures and formalizes the introduction
and the implementation of national quality standards at the level of the social service itself.
6. This manual is also one of the licensing/or accreditation instruments. Generally, this internal
document is assessed within the accreditation process.
7. Finally, it is a “quality manual” and a reference for monitoring and evaluation:
a. for the service as a whole;
b. for the personnel;
c. and for the management performance.
What are therefore the benefits of writing policies and procedures in a service?
The transparency of the service – the staff, users and partners of the organization can easily access
the services’ requirements for care practices. They know what to expect from the service and they
can actively participate to its continuous improvement.
The possibility of constant improvement of the quality of services – once the daily activities are
decomposed in steps and concrete procedures, the improvement initiatives can rely on very
particular aspects of these routines and become less difficult.
The possibility to apply for legal certifications (licensing, accreditation, or other legal
authorizations of the service). Its elaboration is usually mandatory required in the licensing
applications, for social service providers.
Finally, the manual of policies and procedures could become a policy elaboration instrument in a
specific field of action. In countries in which the national quality standards do not exist yet in the
respective domain, the manuals of procedures of various services can contribute (as reference
documents) to the elaboration and formalization of the standards themselves.
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Part 2 – The content and format of the policy and procedures manual –
different possibilities and choices
A.“Standard” manuals of policies and procedures
Which is the difference between “policies” and “procedures”?
How can we identify and select the appropriate policies for our service?
How many policy areas should we include in the manual?
How to organize and update the content of the manual?
 The policy layout
 The procedure layout
 The loose leaf folder and the numbering system
 The manual review and the amendments.
 The distribution list
The “employee handbook”
Recommendations
B.The manual of policies and procedures as part of the overall “organisational
project”
What is an ‘organisational project’?
Why is this document an interesting reference for South East Europe?
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In this part we will describe the most common elements of a manual of policies and procedures. In
paragraph B, we will suggest a possible combination between the ‘standard’ manual of policies and
procedures and a so called ‘organisational project’ (which is the equivalent of the French instrument called
“projet d’etablissement”). This combination of approaches could be interesting for South East Europe, in the
light of the mechanisms of licensing, accreditation and organizational evaluation.
A.“Standard” manuals of policies and procedures
The manuals of policies and procedures are originated in the quality management. As we saw in part 1, they
describe in depth the overall policy of the organization/service and the agreed procedures that are required
in order to reach the policies and goals.
In the social service sector, the manual of policies and procedures is used mainly in the Anglo-Saxon
countries and has a relatively simple structure. It is an organized content, of the most relevant aspects of
one service, together with their correspondent practices/or methodological requirements, that are grouped
in the manual using alphanumeric identifiers, for an easy update procedure.
Each major policy (or domain identified as a “key determinant of quality” for the respective service) is
detailed further on in correspondent procedures and (if the case) task instructions.
What is the difference between “policies” and “procedures”?
As we saw in the previous part, policies and procedures are not the same thing:
- Policies tell us what should be done in the service; they are guiding
principles of an organization, the broad guidelines in the decision making
and the basis for the organisation’s procedures and instructions;
- Procedures explain us how to do activities in a qualitative manner, in order
to achieve the goals and reach the policy requirements. They are a sort of
recipe, telling us how an activity should be done, when, by whom etc.
- As a particular level of detail, each procedure can be further on decomposed
in a flow of task instructions.
POLICY A
Instruction 1.1
Procedure 1
Instruction 1.2
Instruction 1.3
Procedure 2
Procedure 3
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Example: A service promoting the Independent Living might identify as one of the main policy of the
organization “The supported decision making for its users/members”. This policy could be documented with
several procedures like:
- Appointing the support person or support network;
- Identifying the needs for advice and assistance of the disabled person;
- Planning the adequate support together with the disabled person;
- Giving support in decision and choices;
- Giving support in understanding and communication;
- Revision and evaluation of the support etc.
Each of these procedures could be also detailed in very specific (and practical) tasks or instructions. For
example, when referring to the appointment of the support person or support network, one of the first
instructions would be to make a public advertisement about the need for appointing such a person. The role
of the instruction is to precise the very concrete steps of accomplishing this task, who is in charge with it,
how should this public advertisement be done concretely etc.
We see therefore that a manual of policies and procedures is an explanatory document for our service, with
different degrees of generality, progressing from the main areas of activities (policies) to the very concrete
tasks and steps in the respective service. A sort of ‘book of recipes’, which guarantees that all significant
areas of the activities will be carried in a similar way by different members of the staff and will comply with
minimal quality requirements.
How can we identify and select the appropriate policies for our service?
The number of different areas that we would like to regulate through a manual of policies and procedures
can vary a lot from a service to another, depending also on the complexity and the dimensions of the service.
How can we select the most relevant and important issues? How can we avoid transforming the manual in
an overloaded book, of hundreds of pages, that risks not to be used by the staff after all?
There is no single answer for this process. However, the first question that we need to address is “what
means a qualitative service in our concrete field of intervention”? Which are the aspects that define a “good
quality” and which should be well described and monitored in the respective service?
The sources for identifying the most relevant policies for the organisation come usually from the service
itself: we have to find out what users think, what staff considers most significant for the quality of the
service, how managers think, as well as other relevant stakeholders who are directly involved in the service
delivery. Understanding what quality means for our service, we will clearly see what the staff needs to know,
which are those aspects that require in-depth understanding from their side.
We can of course review what other providers think, through literature or benchmarking.
We definitely have to have a look on the Government regulations (specific acts or standards that might
precise concrete domains that have to be regulated within the service itself). If national quality standards
(mandatory) already exist for the respective social service, they constitute usually the main framework for
the service’s manual of policies and procedures.
All in all, we have to focus on the most significant areas of work, which influence in the most critical way the
quality of the respective service. Several examples: ethics, respect of users rights, confidentiality, health and
safety regulations, communication strategies, regular evaluations of activities etc. (In the following
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paragraphs we will give some examples of how thes
main parts of the manual).
e different aspects can be grouped in chapters or
In terms of process, there are usually three main stages for achieving a consensus on these “key
determinants” of quality, among the stakeholders involved directly in the service:
a) A planning, research and assessment stage (1-2 days of common work, with all of them); from
brainstorming to research and more focused discussions, an overall list of policies is realized
progressively, as a common basis for further consultation;
b) A drafting stage, in which the agreed policies are structured in an organized format;
c) A consultation and review stage, in which the relevant stakeholders give a feedback on the policy
draft and agree on a final form. This consultation should lead to clarifications and detailed lists of
procedures for each policy;
The policies and procedures of the organization should be validated by the board of directors or the
administrative committee (in general, by the highest authority of the organization).
Further on, together with the concrete development and implementation of the services’ procedures, they
should be piloted (tested) during an agreed timeframe, in order to check their accuracy and usefulness.
The final form of the policies and procedures will be regularly reviewed and updated, in accordance with the
profile and evolution of the service, as well as with different aspects that need better guidance and
reinforcement. We will briefly present this process in the next sections.
How many policy areas should we include in the manual?
It depends a lot on the size and complexity of the service.
Some policy areas are common to most of the social services: safety regulations, confidentiality, human
resources management, individual plans etc. Other policies reflect the specificity of each service:
A personal assistant service (PAS), for example, will probably have a specific policy regarding the
training of the personal assistants and the way in which persons with disabilities are involved in this
process.
A day care service for children with disabilities will have specific policies for the physical
environment of the children: outdoor and indoor activity spaces, children equipment, assistive
devices and furniture etc.
The important aspect is to keep the focus on “key determinants of quality”, on those areas which are strictly
influencing the quality of the work in the respective service.
Our recommendation would be to keep the number of policy areas as limited as possible, in order to write
the manual of policies and procedures in a “friendly using” format.
In order to facilitate the structuring effort, we also recommend an organization of the content in main
chapters, for example:
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1. General management and administration policies (including financial management, evaluation and
reporting etc);
2. Legal requirements – policies and procedures that are mandatory through the existent legislation
(health and safety requirements, fire prevention procedures etc.), as well as the legal background
(references) for these rules;
3. Service user’s care (the concrete service delivery procedures for each activity area, including as
well the user’s access to the respective service)
4. Human resources policies; in some manuals, this aspect is included in the general management
chapter. We recommend however a separate section on this topic, because of its volume and
particular importance in the social sector.
5. Information and communication policies.
Generally, an organization has few policies and a big number of procedures. The policies are usually public,
the procedures are intern documents, but this aspect can vary from an organization to another.
How to organize and update the content of the manual?
Once the list of policies and procedures defined, it’s time to start writing them in a proper format. It is
important to know that the format of policies and procedures manuals is adapted to a continuous revision
and updating. Therefore, we have to decide a system of headers, footers and/or alphanumeric identifiers
that will help us to organize the multitude of procedures and to have any difficulties in recognizing the last
validated form (chronologically).
1. A standard format of writing is needed not only for the easiness of using the manual, but also for
the evaluation process. The compliance with national or technical standards and the need to meet
the licensing or accreditation requirements leads us to the choice of a format that will be respected
for all policies, procedures and instructions in the manual.
The simplest solution in order to respect this requirement of content formatting is the use of headers
and footers.
The header can precise:
The name of the organization
The type (or the name) of the service addressed by the respective policy section
The title of the chapter and then the title of the policy/ the procedure/ respectively the instruction
The date when the policy was first issued
The issue number
The date the policy was most recently revised
The page number (précising also the total number of pages for the respective
policy/procedure/instruction – ex. Page 1 of 2)
The footer can precise:
The name and the position of the issuing office and the name of the authorizing officer
The signature and date of the authorizing officer
The responsible officer and/or office, meaning the officer and/or office with primary responsibility
for implementing the policy
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EXAMPLE:
Header:
Organization: [name of the organization]
Chapter I : [name of the chapter]
[The name of the service]
[TITLE OF THE POLICY]
[Number of the policy]
Date of issue: [the date]
Date of revision [date 1, date 2, date 3]
[Page x of y]
The body text of the policy/procedure/instruction
(see the details concerning the policy layout and the procedure layout)
Footer:
Issuing office: [the name of the office]
Date of issue: [date]
Authorizing officer [name of the person]
[Position of the person]
[Signature of the person]
The policies layout
Several elements have to be listed in the body text of a policy formulation:
The policy statement – the concrete definition of the respective policy, which should guide the
action and decision making process in the organization;
The reason of the policy – it is important to know if the reason is a legal one, or regulatory, or
legitimating the interests of all parties, prevention of conflicts etc.
The exceptions – the list of all persons/ situations/ locations that are excluded from the policy, if
any;
The persons who should know the policy – it is important to precise who should apply concretely
the policy and its procedures, as well as the persons who should only understand its content;
The list of related documents – the documents that could provide additional or relevant information
for the respect of the policy, including legal texts;
The contact person for explaining the policy or the related elements (exceptions, legal texts etc.)
The list of correlated procedures, with their (alpha)numeric identifiers.
The procedures layout
Because of their nature, procedures have to be very concrete and precise. They have to explain how a
policy will be put in practice, by whom and through which instruments or actions. The layout of the
procedure is therefore declined from its role and will contain the following elements:
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The concrete sequence of events or actions that have to be done; this sequence can be written in
plain text, but also as a flow chart, diagram etc.
The responsibility for implementing the procedure – the position of the person who will implement
the procedure;
The exceptions – the list of situations/ persons/ locations that are excluded from the procedure;
The list of related documents – all formatted documents (tables, sheets, reports etc) that are used
for fulfilling the procedures. If needed, some examples of completed documentation can be
attached;
Archives and records – if the procedure is correlated with the creation of records or if the
documentation is stored and archived, the place of these archives should be mentioned, as well as
the persons who are in charge with the storage;
The instructions layout
Instructions are very detailed working steps or sequencing, within a specific procedure. Their format is
the same with the procedure’s one. Very often, their number is quite big; therefore it is not necessary to
put them all in the policies and procedures manual. They can be included in the so called “employee
handbook”, that will be described in the next paragraph, or become a specific document (booklet,
handbook) of the organisation.
2. Organizing the overall content of the manual is a second step, very important for keeping the
manual in an “easy to read” form, and with consistent information inside.
In the manual, the overall number of policies is organized in thematic chapters (or parts, sections,
volumes etc).
Every policy (or procedure, instruction) can be written on one or several pages, numbered as “page 1of
3”, “page 2 of 3” etc.
The first time a policy or procedure is issued it should be numbered “1”(see the standard format above,
in the header area, on the right side). The amendments will be numbered “2” respectively “3”, “4” etc.
It is recommended to use a loose leaf folder with single sided copies, in order to avoid reprinting of the
document each time when the policies or procedures are amended. Each time when a policy or a
procedure is updated, the respective sheet (or sheets) is replaced.
3. Revision and amendments.
Several persons could be involved in revising the content of the policies and/or procedures. However, in
order to maintain and control the amendments release, one person will be responsible with issuing and
re-issuing the policies and procedures.
The centralization of all amendments is important and can be done in a specific form/ sheet, that is
attached to the manual of policies and procedures. An example of amendment sheet is presented
below:
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No. of
the
record
POLICY
IDENTIFIER
(NUMBER OR
NAME)
Manuals of policies and procedures for social services/2007/
PROCEDURE
IDENTIFIER
(NUMBER OR
NAME)
Date of first
issue
Date and no.
of the current
amendment
Authorisation
officer
Signature
4. Distribution of the manual
The manual has to be distributed among the staff members. A distribution list is attached to the manual,
specifying:
- The date of the first issue of the manual;
- Number of manuals issued;
- Who holds copies of the manual;
- The contact person for manual’s distribution
- The responsible person for issuing revisions to the manual.
It is strongly recommended to train the staff in the field of policies and procedures implementation. All staff
members have to understand the terminology, principles, policy areas and procedures to follow, as well as
the specific procedures and instruction for which they are directly responsible.
The staff has to understand as well the particularities of the service’s evaluation and the modalities in which
the policies and procedures (both elaboration and implementation) are assessed during the licensing of
accreditation processes, or in regular evaluation stages.
The employee handbook
In many performant organization, all personnel-related aspects are integrated in a so called
“employee handbook”.
Service providers can use the employee handbook to integrate (along with job descriptions) information
about the responsibilities of the staff regarding the implementation and revision of policies and procedures.
You can find below the most common elements (the content) of an employee handbook:
Introduction
Mission Statement of the organization
Code of Conduct
Staff related Policies & Procedures
Attendance
Work Schedule Requirements
Staff Meetings
Suggestion Box
Breaks
Compensation
Overtime
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Job descriptions
Wage and Salary Disclosure
Payroll Schedules and taxes
Working Away From the Office
Travels
Performance & Evaluation Reviews
Reimbursement of Expenses
Reporting Personal Information Changes
Personal Property
Personal Safety
Smoking
Organisation Property
Confidential Information Security
Facilities Security
Office Supplies
Organizations’ Vehicles
Organizations’ Equipment
Phone Systems, Voice Mail and Personal Calls
Computer Related Procedures
Computers and Related Equipment
Internet
eMail & Electronic Communication
Policies for Leave of Absence
Eligibility
Personal Leave of Absence
Sick Leave
Short-Term Disability Leave
Unpaid Family & Medical Leave
Funeral Leave
Military Duty
Benefits
Eligibility
Group Medical Insurance
Retirement
Worker's Compensation
Vacations
Education - Scholarships
Discipline Policies
Problem Resolutions
Violation of the Policy of the organisation
Termination of Employment
Termination
Acknowledgment
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Notice
If the organization wants to precise very specifically the responsibilities of the staff for implementing specific
procedures, a correspondent section or chapter can be introduced in the employees manual, with a “map of
responsibilities” within the organization and with all additional details that are relevant for the respective
position or service.
Recommendations
We saw in the previous paragraphs that manuals of policies and procedures are rather regulatory
instruments that help an organization to deliver better its services. These overall systems of written
rules and guiding principles improve significantly the development of an “organisational culture”, as
well as the performance of staff during the daily activities.
However, in order to achieve its role, the manual of policies and procedures has to be a “friendly”
instrument, easy to use, clear, organized and useful.
The elaboration of this manual, in a qualitative way and avoiding bureaucratic effects, requires therefore an
efficient team working. It is recommended though to pay attention to the following elements (you can use
the list below as a checklist), in order to obtain a well written document:
Identify clearly the “key determinants of quality” for your service;
Use these aspects to generate policies and procedures;
Organise the content in clear sections or chapters;
Make a logical link between chapters;
Progress from general information to more specific;
Prepare the table of contents first, in order to see clearly the “map” of the document and the logic
flow of information;
Decide if one manual of policies of procedures can serve your entire organization (and services) or if
each service needs a specific manual;
Prepare the headings that you will use in the manual; decide a unitary format;
Formulate the policies and procedures in clear statements, succinct, with familiar words and avoid
unnecessary technical expressions;
Use short sentences;
Keep in mind the applicative role of the manual; integrate the expectations of users and staff from a
document of this kind;
Link the manual of policies and procedures with the other policy documents of the organization;
check the consistency of these documents one with another;
Prepare well the maintenance of the manual (revisions, distribution). Keep this maintenance
centrally, in order to avoid confusions (especially when many amendments are issued).
Keep well the signature lists and the review records;
Store the manual in an accessible place, in order to be available for the interested persons.
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B. The manual of policies and procedures as part of the overall “organizational
project”
In this section we will propose a comparison between the manual of polices and procedures and the French
“organisational project”2, a comprehensive document which is required by the national legislation for each
social or medico-social service.
What is an ‘organisational project’?
It is a documentation of each social service that defines “the objectives of the service, especially related
with the coordination, cooperation and evaluation of the activities, the quality of the delivered service and
the functioning and organization modalities”
The organisational project is a result of the negotiations between the provider, the users, the staff and the
partners of the service. For the internal staff and for the users, the project defines the profile and the
identity of the service. For the external partners, it justifies the investments and its concrete reasons for
existence. In all cases, it is a reference documentation that put in adequacy the mission of the service and
the resources that are mobilized.
Why is this document an interesting reference for South East Europe?
In our opinion, this document presents a significant interest for the Balkans because it contains (and
combines) several key elements for the current stage of services development in the Balkan area:
A strategic component and a vision of the service on long term. The evolution of the service is
anticipated and described in strategic perspectives;
Modalities for stakeholder cooperation in order to achieve the strategic goals;
A system of shared values among all stakeholders involved in the service provision;
Priorities for action that are derived from the needs analysis as well as the needs of the community;
The adequate measures needed for staff and organisational development, in relation with the
service (project) objectives;
Focus on interdisciplinary team working (where the case);
Focus on internal regulatory procedures that are meant to ensure the effectiveness, the
performance and the good work atmosphere in the service.
In other words, the “organisational project” is a strategic and planning instrument. Its importance comes
from the fact that it combines an analysis of the activity with a broader analysis of the whole organization
in its ‘environment’, and makes the logical link between these two levels.
The project planning in France (in the social sector) has different levels. The providers can develop an
“organizational project”, a “service project”, and of course “individualized projects”, either separately or
integrated in a single reference document.
The organisational project is originated in the need to corroborate the missions and values of the social
service providers in France (non profit in their large majority) with the concrete measures and actions that
In French: “projet d’etablissement”, a document required by the Law 2002-2 (art. L.312-8 of the Code of Social Action
and Family)
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respond to a large category of users needs, in a qualitative way. In the last decade, this tool became a
reflection of the social change, or at least of the change of the institutional framework and modernization
ambitions of the social sector.
An interesting point as well is that the organisational project of the service refers to both:
- Moral/ ethical background and rationale of the service;
- And the operational level, daily routines and activities or staff organization.
The original French tool is not excessively “procedural”, in the sense of the manual of policies and
procedures described in the previous paragraphs. It contains usually the following elements:
A component related to the general framework of the service:
- The historical background of the service;
- The ethical background
- The legislative background;
- The mission statement
- The ‘position’ of the service in its ‘environment’ – adequacy with the local
policies and strategies, with the territorial maps of needs and services,
partnership relationships, geographical position etc.
A component related with the modalities of elaboration, monitoring and evaluation of the
organisational project:
- Description of the project elaboration: methods, external expertise, working
groups etc.
- Participants to its elaboration: users, staff, volunteers etc.
- Evaluation of the previous project: if it was done and how, in order to
articulate it with the current one;
- The validation and dissemination procedure;
- The methodology of monitoring and evaluation of the project.
The service delivery, means and organization:
- The different types of activities developed for the users (the access to them,
the referral procedure, the individual planning process, all actions meant to
facilitate inclusion and participation of users.
For each activity, a certain pattern is required:
a) The type of activity, the outcomes and objectives, their content;
b) The concrete working methodologies (procedures, different types of
standard documentation, meetings etc)
c) The partnerships developed (internally and externally) in order to
accomplish the goals.
- The users (characteristics, origin)
- The organization of the working methods (functional links of the service,
organigrams and job descriptions, the place of volunteers, the regulatory
bodies (assessors, auditors, consultants etc), risk management and so on)
- The human resources policy and procedures
- The financial and administration management
- The evaluation methods of the organization and the service.
Finally, the perspectives of the service and its further evolution.
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This part places the service in a dynamic evolution on 3-5 years and more.
Providers have to explain the choices for this evolution and linking them
with the wider context in which the service exists. It takes in consideration
the ‘diagnostic’ of needs at local level and represents as well a planning tool,
both for the provider and for the decision making body at local level.
The organisational project has to contain in attachment all financial, staff-related, management
related forms or documents, as well as the ethical charts, the codes of conduct, the internal
regulations etc.
It is a subject of analysis and discussions if these two different regulatory instruments (the manual of
policies and procedures, respectively the organisational project) could be combined in one.
However, we propose to open the debate on this topic and to acknowledge the interest of introducing
qualitative and more comprehensive tools for the service development and improvement, in this region.
In a period in which the reform processes are ongoing in the social sector, methodological instruments like
these ones can bring a lot of added value:
they can place the social service in a dynamic and long-term thinking; they are prospective and
strategic, focusing on the service’s evolution on long term;
they can define the internal regulatory methods, as main condition for accountability and good
governance;
they can better link the service delivery with the users’ needs and with the wider context in which
the service is rendered;
finally, they give precision and concrete references for what “good quality” means in a social service,
which makes the quality review and improvement possible.
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Part 3 – Responsibilities regarding the overall manual of policies and
procedures
Who elaborates it?
Who revises it?
Who is in charge with the copy and distribution of the manual to new staff
members?
Who is in charge to train the staff for the manual implementation?
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Who elaborates the manual of policies and procedures?
A working group that involves all relevant stakeholders for the respective service: users, staff members,
administrators, partners, volunteers etc.
If the differences in values, background, interests between these participants are too big, it is recommended
to use a facilitator. Be sure that all valuable (and agreed) propositions are recorded at the end of the day…
and be free to transform this process in an enjoyable time with your partners and service users.
Finally, the Board or the Management Committee has to validate the final document. It will become the
reference document for your service.
Who develops and revises it?
It is recommended that the procedure of revision and updating is included in the manual itself. Regular dates
for reviewing the manual should be mentioned as references (usually each 6 months-one year).
The Board/Management Committee, as well as the staff itself, can look at the organisational manual every
12 months and ask whether the policy in it is still relevant and appropriate. If not, a process like the one
above would be followed to revise existing policy or develop new policy
In small organizations the staff and the manager of the service can allocate some time each month, during
the staff meetings, in order to brainstorm issues related with the different policy areas. Of course for each
revision, the management board will have the final word in the validation process.
Who is in charge with the copy and distribution of the manual to new staff members? Who will
train the staff accordingly?
Once the policy manual is validated, it is communicated to all the relevant people and if necessary, a date is
set for a training/information session to ensure all staff has the knowledge and skills to implement the
policy. The responsible for this process should be the manager of the service, or a designated staff member.
It would be helpful if this responsible and the authorization officer (the one responsible with issuing the
amendments) is the same person.
In some organizations, the responsible with the maintenance and distribution of the policy manual is called
“policy custodian”. Staff should be made aware of the manual and a written copy or electronic format
should be available at all times.
The responsibility for training the staff is usually assumed by the manager of the service. He is the one that
has to mobilize resources and time, in order to allow the staff the training in all aspects related with the
manual implementation.
The manual should be used as well to assist the appointment and training of the new employees.
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ANNEX 1 (Updated in December 2009)
The following text is an extract of the Manual of Policies and Procedures of the Commissions for Evaluation
and Orientation of Children with Disabilities in Montenegro.
These commissions are one of the main gate-keepers for children with disabilities in this country. Within a
complex process of reform in the education and child protection systems, they have been established and
started to work in 2008. In 2009, a working group among the commissions’ members have elaborated a
specific (and comprehensive) manual of policies and procedures, which is now disseminated and used in all
commissions at local levels.
The example presented below is related to the way in which the policy on “Confidentiality” was formulated
in this manual. It illustrates the way in which the format and the content of an internal policy could look like.
The words: “header”, “body text” and “footer” have been added by us in order to highlight the position of
these elements on the page.
HEADER:
Local Council of Niksic - Evaluation Commission
Chapter 6 – Confidentiality of information
POLICY NO.6 – Confidentiality of information
Page X from y
Code:……..
BODY TEXT
POLICY no. 6 – CONFIDENTIALITY OF INFORMATION
START OF THE CHAPTER
6.1 PURPOSE OF THE POLICY
Sharing information is vital for early intervention to ensure that children with additional needs receive the
services they require. It is also essential to protect children from suffering significant harm.
Practitioners are sometimes uncertain about when they can share information lawfully. It is important
therefore that they:
- Understand and apply good practice in sharing information as part of preventative work;
- Are clear that information can be shared where they judge that a child is at risk of significant harm;
- Understand what information is and is not confidential, and the need in some circumstances to
make a judgment about whether confidential information can be shared, in the public interest,
without consent;
6.2. LEGAL REFERENCES FOR THIS POLICY
6.3. DEFINITION OF CONFIDENTIALITY (What is a confidential information?)
The Evaluation Commission considers information about individuals to be ‘sensitive’ - and therefore to be
treated as confidential - in the following areas:
 health matters, and in particular, HIV status and other communicable diseases
 offending background
 family and/or dependent circumstances
 biographical details, such as history of abuse or local authority care.
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Personal information relating to previous housing, educational history and employment background may be
shared with other staff as it is important in informing the development of an effective individual support
plan.
6.4. CASE RECORDS
6.4.1. It is the responsibility of the President of the commission to ensure all case records are kept securely.
This includes notebooks, copies of correspondence, evaluation forms, support plans and other sources of
information.
6.4.2. All commissions’ members are given guidance on the safe storage of information relating to service
users.
6.5. STATISTICAL RECORDING
6.5.1. The commission is committed to effective statistical recording of service users to enable the monitor
of children’s situations and to identify any policy issues arising from advice services.
6.5.2. It is the responsibility of the President of the Commission to ensure that all statistical records given to
third parties, such as to support funding applications, monitoring reports for the local authority shall be
produced in anonymous form, so individuals cannot be recognized.
6.6. OTHER GENERAL PROCEDURES FOR ENSURING CONFIDENTIALITY
6.6.1. All staff should ensure that no discussions relating to an individual user take place where they can be
overheard by a third party.
6.7. EXPRESSED CONSENT REGARDING PERSONAL INFORMATION
6.7.1. It is the responsibility of commissions’ members to ensure that where any action is agreed to be taken
by the commission on behalf of a client, that client must firstly give their consent which should be recorded
in the Case record.
6.7.2. The Commission is responsible for checking with clients if it is acceptable to call them at home or work
in relation to their case.
6.7.3. The Commission is responsible for checking with clients that it is acceptable to write to them at home
or work in relation to their case.
6.7.4. All details of expressed consent must be recorded in the case record.
6.8. EXCEPTION OF CONFIDENTIALITY
6.8.1. In deciding whether there is a need to share information you need to consider your legal obligations
including:
 whether the information is confidential; and
 if it is confidential, whether there is a public interest sufficient to justify sharing the information.
6.8.2. A public interest can arise in a wide range of circumstances, for example, to protect children or other
people from harm, to promote the welfare of children or to prevent crime and disorder.
6.8.3. Where the safety and welfare of children are at risk, their protection takes precedence over the
requirement for confidentiality.
6.8.4. On occasions where a member of the commission estimates that Child Protection may be an issue, the
following steps must be taken:
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
The member of the commission should make notes of any events/ discussions causing concern as
soon as possible.
 The member of the commission should raise the matter immediately with the President of the
Commission.
6.8.5. The President is responsible for making a decision whether or not to contact Social Services about the
matter.
6.8.6. A full written report on the case should be made and any action agreed, undertaken.
6.8.7. The President is responsible for ensuring that all activities are undertaken by the responsible persons.
6.8.8. Commission should ensure that the information they share is accurate and up-to-date, necessary for
the purpose for which they are sharing it, shared only with those people who need to see it, and shared
securely.
END OF THE CHAPTER
FOOTER:
Issuing office: ……………
Authorizing officer: ………, President of the Commission
Date of issue: 1.01.2008
Date of revision: 23/ 04/08, 5/05/08
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