Part IIObjectives

Describe how policies and procedures are used Identify different types of P & P Describe the purpose and components of a

Policy on Policies Explain the approval and review process for

policies and procedures Describe suggestions for writing policies and

procedures

When to Write or Revise P & P

Starting new or when changes occur When required by legislation/regulation

Policies must take into account various levels of legislation/regulation which impact health care delivery

When to Write P & P

Examples:

– Federal government establishes health care legislation

and funding, e.g., Title X regs– State government takes action in accordance with

Federal legislation, e.g., state statutes, admin. code, program regulations

– Local government plans for mandated services and decides whether to offer non-mandated services. Decisions are made at several levels.

Use of P & P

Administrators manage in accord with policies

Administrators design procedures to carry out policies

Examples– fiscal procedures– program protocols– purchasing procedures

When to Write P & P

Examples cont’d:– Levels of decision-making:

• Board of County Commissioners

• Board of Health

• Local Health Department/Health Director

• Program Area

These decisions form the basis for policies and procedures

When to Write P & P

Examples:– Federal level--HIPAA, OSHA– State level--Nurse Practice Act, Bd of

Pharmacy regulations, program policies– Local level--County ordinances, various

county-wide policies– Agency level--P & P to carry out the work of

the agency

Types of Policies and Procedures

Agency Policies– a broad description of what agency does and

why– include the objectives, rules, and regulations

which guide agency activities and direct allocation of resources

– should be consistent with agency mission statement, strategic plan & community assessment

Types of Policies and Procedures

Program Policies– describe the what and why as they apply to

individual programs– include the objectives and rules which direct a

specific program focus and activities– should be consistent with overall agency

policies

Types of Policies and Procedures

Procedures– describe in detail how and by whom the work is

to be done– should be consistent with policy statements

Protocol– the plan for processing patients through a given

program – a treatment plan used by mid-level practitioners

Types of Policies and Procedures

Standing Orders– the framework for Registered Nurses to assess

and treat disease while practicing in local health department settings

– signed instructions of a physician which outline the medical assessment, appropriate testing, and treatment performed on behalf of the physician

– standardize the clinical care practiced– require no medical decision-making by nurse

Policy on Policies

A policy that governs the policy development process

Describes the process used in your agency to develop policies and procedures

P on P should address the following components:– who initiates the process

– who writes

– format--type face, margins, headings

Policy on Policies

Components, cont’d:– identification system, e.g., by name or number– organization system, manuals vs. stand alone

policies, electronic, intranet, internet– writing style– approval process– review and revision cycles

Policy on Policies

Components cont’d:– education and distribution– archiving

Sample Policy on Policies in handouts

Approval and Review Process

Policy on Policies should provide – direction on who approves policies– define review and revision cycles

Approval– policy should be signed by the individual

approving the policy– date of approval should be recorded

Approval and Review Process

Review and revision cycles – may be the same for all P & P – may be different for groups or categories of

P & P Recommend P & P be reviewed and revised

as needed and at least annually

Policy Development Process

Suggested steps:

1. Define the issue, problem or task

2. Determine responsibility for writing

3. Involve all disciplines who will be affected and are involved in carrying out the program

4. Involve medical consultant when developing policies related to clinical services

Policy Development Process

Steps cont’d:

5. Use an agreed upon template or format

6. Write draft of the policy or procedure

7. Review and analyze the draft

8. Revise the draft as necessary

9. Do final review

Use of P & P

Boards adopt policies to guide the work of an organization

Boards govern by policy Examples of policies adopted by Boards

– fiscal policies– program policies– personnel policies

Policy Development Process

Steps, cont’d:

10. Make final revisions

11. Adopt the policy or procedure

12. Distribute policy or procedure

13. Educate staff

Policy Development Process

Steps, cont’d:

14. Implement the policy/procedure

15. Conduct on-going evaluation/revision per policy on policies

Policy Development Process

REMEMBER:– Some policies should be reviewed by:– County Attorney – County Manager – Personnel Officer – Medical Advisor– Other as appropriate