Effective Policy Writing and Management

Policy writing and management is a critical administrative component of any health center.

These documents provide an accounting of governance, purpose, and implementation

expectations roles and responsibilities of key functions and processes. In this article the

following are explained as a guide to understanding the value of policies and policy

management and steps to facilitate effective policy writing.

• Why documentation is so important: Tips that could keep you out of trouble later.

• Who should write policies (qualifications of good policy writers).

• What are the differences between policies and procedures.

• When to use handbooks, manuals, flowcharts vs. policies.

• How to achieve consistency using standardized policy attributes and format.

• How to organize policies (classifying and numbering).

• When policies should be reviewed and/or revised.

Why Write Policies and Procedures?

The answer is easy. To satisfy various laws including HIPAA, HRSA, IRS, and other federal, state,

and local laws, and accrediting entities such as The Joint Commission (TJC), the Agency for

Accreditation of and/or the National Committee for Quality Assurance (NCQA). Additionally,

the new IRS Form 990 asks whether nonprofits have certain policies relating to governance. You

don’t want to answer “no”.

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

and procedures

� Provide quick settlement of misunderstandings

� Help reduce the range of individual decisions and discourage management by exception

� Cover recurring situations such that managers can begin to make decisions that will be

consistent every time

� Set 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

The IS and the ISN’T in Effective Policies and Procedures

What “Writing” IS?

Writing policies and procedures is more than typing words on a page; it involves research,

writing a draft, reviews, approvals, publishing, distributing, communications, training,

maintenance, improvements, and revisions. Writing means to write consistently using a

consistent writing format and writing style. The writer of policies is someone who understands

how to gather the information, document a process, present the words in a logical fashion, and

publish and train the audience to ensure the content is understood.

What “Writing” ISN’T?

Writing is not developing content in a vacuum without involving the users and customers in the

writing and reviewing processes; buying canned content, attaching a logo, and calling it your

own without sanitizing it to assure it aligns with our environment, culture, and resources; and

expecting non-writers to write high-quality policies and procedures that people will understand

and follow (a writer of business letters does not make a good policies and procedures writer).

In.

Qualifications of a Good Writer Policy writing is an art and takes skill to craft these documents. Roles and responsibilities of

policy writers should include the ability to identify policy topics, conduct research about the

topics, format drafts and circulating to appropriate individuals for review of content and

process, issue communication of new and/or revised policies throughout the health center,

conduct training, and manage the documents for review and renewal timeliness.

There are good choices and not so good choices you can make when identifying who are the

policy writers in your health center.

Good Choices

� Someone with writing and editing skills who has the time and mobility to interview users

and customers

� Someone who has worked on process improvement projects

� Someone with excellent organizational skills and a passion to write documents that can be

understood by the targeted audience

� Analysts, Subject Matter Experts, Leads, Supervisors, and some Managers

Not So Good Choices

� Individuals who write business letters and correspondence but have never (or

infrequently) written policies or procedures

� Individuals who have the knowledge but don’t have the time

� Individuals that take content from others and format it in their own style but don’t

interview users to ensure the content is correct

Policies vs. Procedures Defined Often policies include day-to-day operating procedures within the body requiring protocols to

be managed as a policy requiring heath center Board approval. This can be a time and resource

intensive process each time a protocol/procedure needs to be revised.

Policies:

� Describe the “What” the “Who” and the “Why”

� Are a predetermined course of action established as a guide toward accepted business

strategies and objectives

� Are guidelines dictated by executives and/or extracted from regulations”

Procedures:

� Describe the “How” and are generally methods by which policies are accomplished.

� Are a combination of one or more business processes

� Identify the people, places, processes, forms, and actions necessary to carry out one or

more policies or to support or influence other procedures

� NOTE: Procedures that address a single process such as how to complete a form or cash a

check should be referred to as “Desktop Instructions” or “Work Instructions” and

complimentary to procedures.

Getting Starting: First steps in establishing a policy framework BEGINS with 5 Agreements.

AGREE on the importance of a writing format and agree on which writing format to use in

which situation.

AGREE on the use of a single writing format for policies and procedures or two writing formats

for policy and procedure documents; and one desktop instruction format.

AGREE on communications media to be deployed.

AGREE on training methods to be utilized and repeated.

AGREE to write a “Policy on Policy Writing and Management” to capture the essentials of

writing policies and procedures.

Questions to Answer Before Writing Starts

1. What’s the justification?

2. Who authorizes?

3. Who manages function?

4. Who writes policies and procedures?

5. Do you deploy printed and/or online manuals?

6. Do you use 1 writing format, 2 writing formats; and desktop instruction formats

7. What’s your document numbering system?

8. Where does content come from?

9. What’s the layout of your writing format?

10. Are forms designed to align with policy and procedure content?

11. Who reviews drafts?

12. Who approves drafts?

13. Who distributes and publishes documents?

14. Who communicates?

15. Who trains?

16. Who audits?

17. Who monitors to ensure current regulations are taken into consideration?

18. Who recommends improvements?

Writing Format SECTION HEADINGS

Header – Logo, title, number, dates, approvals, revisions

1.0 Policy Statement

2.0 Responsibility

3.0 Definitions

4.0 Implementation (Procedures)

5.0 Documentation/Monitoring

6.0 References

7.0 Related Policies and Procedures

Optional documentation (appendices can be used as a way to include flow charts, diagrams,

and other material)

Adding Section Headings

� Possible additions include “Background,” “References,” “Document Approvals,” or

“Disciplinary Actions”. If you add more headings, integrate them into the writing format

and stick with that number of section headings

� Never deviate for any reason: Consistency is King

Desktop Procedures Instructions Writing Format

Remember procedures are the “How” of workflow processes and identify the people, places,

processes, forms, and actions necessary to carry out one or more policies or to support or

influence other procedures. The writing format should be different from the policy format and

usually does not require Board review and approval Below is a suggested format

The Policy Attributes Policy attributes are included in a policy to provide mechanisms for historically documenting

the lifecycle of a policy, organizing identifiers, and applicability for distribution and training. Let’

look at common policy attributes.

Header Information (All Writing Formats have Header, or Title, information)

� Logo

� Title

� P/P Number

� Department/Operational Area

� Effective Date

� Review, Revision, and Approval Date

� Approvals

� Page Numbers

� Scope

1.0 Policy Section Heading

The Policy section heading describes objectives, strategies, goals, culture, vision, mission, and

other guiding principles for the topic stated in “TITLE” and “PURPOSE”. It can be a single

paragraph, several sentences, and sometimes several pages. The opening sentence might say:

“The policy of XYZ company is to: (Follow with statements or indented sentences)”

Be careful:

� Don’t omit the “Policy” section heading

� Write policy statements that support the main focus of the “Purpose” section heading or

the “Title” of the document

Header Information Policy Statement Examples

2.0 Responsibilities Section Heading

This is a summary of roles and responsibilities of the individuals or groups that perform actions

in a policy or procedure. The “Responsibilities” section often parallels the flow of the

“Procedures” section, where applicable. The responsibility section typically has at least two

sentences:

� “The [Title of Highest Approver] shall ensure compliance to this policy (or procedure)”

� “Employees are required to…”

Be Careful:

� There must be a “compliance” statement in every policy or procedure document

� Don’t write procedural statements in this section; rather keep to the responsibilities of

the roles stated

� Don’t write actual names of persons; instead state only their roles or functions

3.0 Definitions Section Heading

The definitions section heading defines objects or terms like acronyms, abbreviations, forms,

reports, flow charts, models, words infrequently used, or technical jargon. Don’t assume your

audience has the same vocabulary as you.

Be Careful:

� Never omit a section heading

� Not to leave this section blank: All policies and procedures have definitions of some sort.

4.0 Implementation / Procedure Section Heading

The Implementation section heading describes the rules, regulations, activities, timing, place,

and personnel necessary to carry out the intent of the procedure and/or support the essence of

the policy statements contained within the Policy section heading.

Be Careful:

• Ensure that the procedural statements support the policy statements

• Ensure that the procedural statements follow the work flow that is usually in an

accompanying desk procedure or operating protocol

• Keep this section at a policy level and use desk procedures for specific “How To” details.

5.0 Documentation / Monitoring Section Heading

The documentation section contains information related to documentation requirements. It

describes any surveillance and or monitoring activities to ensure/track compliance

Be careful:

� Assure that all monitoring requirements are included in quality assurance/quality

improvement planning.

� Don’t omit this section.

6.0 References Section Heading

The reference section heading contains information related to references used in writing the

policy content. For example:

7.0 Related Policies Section Heading

The related policies section heading crosswalks all related policies, procedures, and perhaps

additional documents. It assists in managing consistency across documents when needed

revisions are needed. Writers should conduct a consistency review of all related documents

listed in this section when revising to ensure consistency remains throughout.

Optional Documentation

Optional documentation can be added to any policy or procedure document. One method is to

define the documentation (like a flow chart or report) in the “Definitions” section and refer to

an appendix where the document has been included. Another method is to hyperlink a

reference for electronic policies and procedures (opens in its own window). In the case of a

form, define it in the “Definitions” section, and either add a hyperlink to the template or in the

case of paper forms, give directions on where to find the form (like a supply cabinet) and show

a sample image in an appendix.

Be Careful:

� Don’t include an appendix without a reference notation from somewhere in the

document or from the “Definitions” section.

� Don’t include a reference in the “Definitions” section and then fail to include the actual

reference document or source either as a hyperlink or as an appendix to the document.

Quick Ways to Write Policies and Procedures from Canned Content There are two common methods to do this:

Method 1: The Quickest, but acceptance is difficult, is to find or purchase a canned (generic

content) policy or procedure you like from a website or book, don’t change a word, add your

logo, and call it your own. Unless you adapt content to your culture and people, buy-in is highly

unlikely.

Method 2: The Best method is to assign at least one writer and/or form a cross-functional

team, do research, use canned content for reference purposes only. Interview users,

brainstorm ideas, write a draft document, get it reviewed and approved, publish it,

communicate and train.

AND THERE IS MORE...

Once the policy document has been written, reviewed, approved, published, and distributed

there is the act of implementing, monitoring for complete and accurate implementation, and

sustainability of implementation over time. Guidelines to consider are:

� Communicate the information and use the documents to train your employees

� Manage the documents content and expiration dates

� Work on improvements for the next revision

� Update the document, publish the revision

� Re-communicate and retrain... and so on

Communications are key to policy/procedure implementation because it’s a quick way to

impart information about policy/procedure content.

Communication Methods can include:

� Document management applications like PolicyPLUS

� Distribution of physical or electronic documents

� Letters, press releases, newsletters

� Paycheck stub or inserts

� Posters, bulletin boards, or brochures

� Team meetings, town meetings, staff meetings

� Email messages or broadcast emails

� Intranet news items

Provide communications in multiple ways to give the reader added ways to understand the

material. Keep in mind that the “just once” communications method and plan is not acceptable

and plans must be made to communicate regularly to ensure continued understanding on the

behalf of the employee and to reduce the tendency to “resist change”.

Training is critical to policy effectiveness and is defined as to make prepared, to teach to be

proficient, to undergo instruction, or to practice. In business, training is the formal process

used to develop in an employee the attitudes, knowledge, and skills an employee needs to

make him or her capable of efficient performance (i.e., less time to carry out assignments).

Training methods include but are not limited to:

� Document training management applications like PolicyPLUS

� Lectures, workshops, or seminars

� Department or staff meetings

� On-the-Job Training

� Multimedia training and/or computer-based-training

� Mentoring and coaching

� Other creative training methods

The key to sustained implementation is to train and then to repeat training through on-the-job

training and mentoring.

In summary there are necessary policy writing ingredients necessary to ensure success. These

include:

� Management commitment to write policies and procedures

� Qualified writers---More than just an editor

� Same writing format template used every time

� Communications issued in multiple media

� Training offered in a variety of formats

� Walk the talk from management

� Mentoring and On-The-Job Training

� Ensuring legal review of all relevant policies

� Management of the documents and training with documentation

� Regular timelines for policy reviews

� Adding policy understanding as part of an employee’s annual evaluation

Summary

1. Select a writing format and stick with it

2. Write a policy on policy writing and policy management and stick with your decisions as

you write policies

3. Designate a policy writer and give this person the tools, time, and mobility he/she needs

to be successful

4. Don’t expect to be able to take a canned policy, make a few changes, add a logo, and call

it your own if you actually want people to read and apply the content

5. Put a policy writer in charge, follow the guidelines, and do it right the first time...so that

readers might actually read the documents and apply the guidelines to their jobs

6. Be proactive, as you are doing today, by reading this article, and learning tested methods

for writing effective policies and procedures

A webinar presentation, titled Effective Policy Writing and Management, which contains

additional information to compliment this publication, along with numerous other free health

center related training tools and resources, may be viewed at http://www.qfms.org/policyplus-

resources.html

Co written by

Randal F. (Randy) Chitty

President/CEO Quality First Management Solutions, Inc.

www.Qfms.org

And

Candace J. (Candi) Chitty, RN, MBA, CPHQ, PCMH CCE

President/CEO Quality First Healthcare Consulting, Inc.

www.Qfhc.com