Taking a Systematic Approach to Hospital Policy Development

Using a standard format for all organizational policies makes it easier for staff to read and retain information, as well as scan documents later for specific guidelines and rules.

Ever since the federal sentencing guidelines for organizations became effective in 1991, the first and most important criterion for judging compliance program effectiveness has been establishment of clear “standards and procedures to prevent and detect criminal conduct.”

Although this has been the case for a quarter century, I continue to see organizations with deficient policies and procedures for the following reasons.

• Poorly written
• Too complicated or simplistic
• Inconsistent in style and format
• Out of date
• Hard to find
• Not centrally managed

To avoid these and other problems, compliance officers, risk managers, and legal counsel must take a systematic look at their organizations’ policies and policy-management processes. The following are some thoughts on policies and procedures developed during my four decades of working in and for healthcare organizations.

What is a Policy?

The first step in assessing policy systems is to understand what policies are and how they differ from procedures. The two terms are sometimes used interchangeably, and while they do go hand in hand, they are not the same.

Policies are general principles that govern behaviors. They are organizations’ fundamental positions on issues. Procedures, on the other hand, describe the steps necessary to implement policies and achieve organizational goals. Organizations’ underlying policies do not change often, but implementing procedures should evolve over time in response to changing circumstances.

For example, a tax-exempt hospital might have a policy stating that it will not engage in political campaign activity (i.e., it will neither support nor oppose candidates for public office) but that it will host candidate forums and engage in other nonpartisan activities. Its procedures would outline the kinds of nonpartisan activities that are permitted and the steps necessary for getting internal approvals. If the tax regulations or internal processes change, the procedures would change but the underlying policy would not.

Although in some organizations the policies and procedures are separate, it is preferable to put procedures in the same document as the policy itself. To have the procedural steps separate from the policy requires readers to consult multiple documents and thus increases the risk of noncompliance.

A Policy on Policies

Effective policy management begins with a policy and procedure document that outlines the policy-development process. This document must describe how and by whom policies are drafted, how review by affected stakeholders is achieved, and who has authority for final approval. It must outline who is responsible for communication and education, how policies are maintained and periodically reviewed, and how accessibility is assured.

Ideally, the policy on policies should require creation of a policy management committee and should assign responsibility for oversight of the whole process to a single individual or office. For example, the University of California has a University Policy Office (UPO) within the Office of the President. The UPO “oversees the policy-making process in all areas for which the president has authority [and] involves broad consultation with diverse university constituencies on ten campuses.” In addition, that office is the official repository of historical and current policy documents, and all its policies are searchable online.

In my experience, hospital leaders can assign the role of policy manager to the chief operating officer, the chief compliance officer, the head of risk management, or any other individual high enough in the organization to coordinate policy development across departmental lines. Depending on the size of the organization, it could even be a full-time position―akin to the University of California’s UPO―that reports directly to the CEO.

Policy Content

Policies and procedures must be written and publicized to be effective and binding. If they are not, organizations can’t fairly hold people accountable. For example, if managers say, “It’s always been our policy to do XYZ,” what they really mean is that XYZ has been their practice. But “practices” are not policies, and “we’ve always done it this way” is a dangerous attitude because people who are unaware of a practice can be blindsided.

Not only must policies be in writing, they must be written clearly and concisely, in a standard format throughout the organization, and readily accessible to affected employees.

Clear, concise language. In one organization I am familiar with, all major policies were reviewed by a committee―chaired by a representative of the risk management department―that included the compliance officer and representatives of other major departments as subject-matter experts who provided substantive content. A single editor―chosen for good writing skills―was the final arbiter of style and readability.

The editor focused on avoiding ambiguities and keeping the policies concise. The rule of thumb was to try to limit policies and procedures to two pages, and the editor found that this could often be achieved by putting details in attachments. The editor also gathered usage pointers that were shared on the organization’s intranet.

See related tool: Policy Language Usage Tips

A clear policy needs unambiguous definitions of terms that may be unfamiliar to the reader or are used with uncommon meanings. I recommend defining a term in the body of the policy at the first instance of its use. Some writers prefer to define terms in a separate section of the policy. If you choose the latter, I suggest putting that section near the beginning of the policy so it is not overlooked.

Standard format . Using a standard format for all organizational policies makes it easier for staff to read and retain information, as well as scan documents later for specific guidelines and rules. For example, one organization had a variety of formats because it had grown over the years by acquiring numerous independent facilities, each of which used one or more different formats. But when the time came to adopt a system-wide policy on a topic, it was virtually impossible to sort through the disparate and often conflicting policy statements found in the various facilities.

Ultimately, the system in question adopted a standard format, which helps policy writers to organize their thoughts and helps readers know where to find what they’re looking for.

See related tool: Policy Template

The standard format should specify the font to be used, font size, margins, line spacing (usually single), and similar design and layout requirements.

Accessibility . Above all, policies and procedures must be accessible to everyone who has a need to know. If people can’t find them, they might as well not exist. For many years, policies were distributed as paper copies and collected in ring binders or manuals with a table of contents. The drawbacks of such a system are that ring binder perforations rip and pages get lost; people fail to insert page changes when they are published; entire binders or manuals are missing when they are needed, and users may not use a standard method for organizing information.

For example, I was looking for a facility’s organ donor policy but it wasn’t listed in the policy manual index. When I asked a staff member where to find it, I was told that the policies were listed per the title of the applicable state statute. In this case, the statute was named “Routine inquiry for organ and tissue donation,” so the policy was listed under “R” in the index―not a logical choice for most users.

Problems like these make accessibility an ongoing headache for outdated, ad hoc policy systems. Fortunately, there are online policy management applications available that overcome accessibility hurdles. For example, those applications make all organizational polices available on a hospital’s intranet for easy access.

Legal experts and governmental authorities consistently recommend that the following be included in policy and procedure documents.

• A precise purpose statement explaining why the organization is issuing the policy and procedure and its desired effect
• An explanation of whom the document applies and, if applicable, who is excluded from its requirements
• The effective date and prior revision dates―in other words, the revision history
  • The name or title of the person who has decision-making (issuing) authority and accountability
• Clear definitions of terms and concepts used that can be hyperlinked to an online glossary
• Specific action steps that must be followed (i.e., the procedures)
• References and supporting documentation that may include forms, flow charts, and background material

These recommendations are incorporated in the sample format shown in the “Policy Template” tool mentioned earlier.

Other Suggestions

An inventory of the policies and procedures that exist in your organization, be they formal policies or informal practices creates a good starting point to evaluate your current position  (Remember that customs and common practices are not policies, but they will prevent your policies from being implemented correctly if you don’t know about them. Other recommendations include the following.

• When writing or revising a policy, benchmark against similar organizations.
• Send a first draft to subject-matter experts and affected persons for their review.
• Use headings and subheadings to guide the reader.
• When proofreading, do not rely solely on the word processor’s spelling and grammar check function.
• Once the policy has been adopted, ensure that monitoring processes are in place to test for compliance.
• Ensure that policies are reviewed regularly and updated as necessary.
• Archive expired policies per legal requirements and your organization’s records-retention policies.

Three Important Rules

Finally, three rules will ensure clearly written policies and procedures.

Know your audience. Make sure your style fits the reader. For example, you might use a different vocabulary and reading level for clinical personnel than for the general public.

Be scrupulous with punctuation . Punctuation is important. If you wrote, “A panda eats, shoots, and leaves,” the reader might think that cute furry animal had a handgun.

Think about readers’ interpretations. Think about what the reader will understand. We speak to be understood, but we sometimes write to make it impossible to be misunderstood. In other words, what you mean isn’t important; what’s important is what the reader thinks you mean. Ask others to read your work to make sure the correct message is being conveyed.

Clear Policies and Clear Communication

Well-written policies and procedures help hospital staff perform their jobs efficiently and effectively. Not having to guess or assume the best course of action contributes to smooth operations and increases the time staff spend ensuring patient satisfaction and good clinical outcomes. 

Sample Policies and Procedure Documents

“Presidential Policies” (overall policy process coordination), Regents of the University of California, University Policy Office.

HCA Ethics & Compliance, HCA Holdings Inc.

Policy and Procedure Development, HCA Holdings Inc.

Guide to Writing Policy and Procedure Documents, University of California Santa Cruz (1994)

Books and Articles

Campbell, N., Writing Effective Policies and Procedures: A Step-by-Step Resource for Clear Communication, New York, N.Y., American Management Association, 1997.

Page, S. 7 Steps to Better Written Policies and Procedures, Westerville, Ohio, Process Improvement Publishing, 2001.

Page, S. Establishing a System of Policies and Procedures, Westerville, Ohio, Process Improvement Publishing, 2002.

Shaw, H. Errors in English and Ways to Correct Them, HarperCollins Publishers (1993).

Shope, B. “True Writing is Rewriting,” Vision: A Resource for Writers (2002).