Part II Objectives

Part II
 Describe
how policies and procedures are
 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
 Administrators design procedures to carry
out policies
 Examples
– fiscal procedures
– program protocols
– purchasing procedures
When to Write P & P
 Examples
– 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
– a broad description of what agency does and
– 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
Types of Policies and Procedures
 Program
– 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
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
– a treatment plan used by mid-level practitioners
Types of Policies and Procedures
 Standing
– 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
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
– who initiates the process
– who writes
– format--type face, margins, headings
Policy on Policies
 Components,
– 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
– 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
 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
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,
Make final revisions
Adopt the policy or procedure
Distribute policy or procedure
Educate staff
Policy Development Process
 Steps,
14. Implement the policy/procedure
15. Conduct on-going evaluation/revision
per policy on policies
Policy Development Process
Some policies should be reviewed by:
County Attorney
County Manager
Personnel Officer
Medical Advisor
Other as appropriate