We all are working together to fulfill common core causes. Yes, we—even those of us in information systems and information technology—are here to ensure patients and staff are safe and healthy.
Policies and procedures serve several roles, but one core role is to ensure this safety. Policies can be thought of as very high level guidelines defining ways in which we, as team members, can shape decisions toward our organization’s mission of helping our patients.
Procedures, on the other hand, provide clear guidelines for lower-level processes clarifying specific steps team members need to take to ensure they are adhering to your organization’s policies. These policies and procedures can often serve to show compliance to current standards (treatment standards, security standards, or operational standards).
What most organizations have trouble with is making sure policies and procedures are as accessible as possible.
The challenge in policy and procedure management is ensuring that team members can easily get to specific procedures and managers can check up on policies to ensure their current procedures are complying with the organization-wide policy.
Often we see organizations that spend a lot of time and money creating their policies and procedures manuals, but end up with documents that aren’t used effectively—staff that cannot easily find and implement the procedures that are needed on the job.
The bottom line: when creating and presenting your policies and procedures, you want to make sure your team is able to read and access information easily.
There are many areas that can affect the accessibility of policies and procedures:
- Table of contents and hyperlinks to specific policies and procedures
- Clearly named documents that identify the purpose of the policy or procedure
- Material logically organized in sections within a policy or procedure
- Numbered policies and procedures that make linking up different documents easy
- Breaking text into chunks to aid a rushed employee to find information quickly, including bulleted steps, graphics, diagrams and headings
- Clearly numbered and labeled paragraphs, which make finding a specific section within a policy or procedure easy to access and limiting the number of levels within a policy or procedure to make them easily readable
But one of the biggest challenges to policy and procedure management might be even simpler than all of the different considerations listed above.
One of the easiest ways to make your policy and procedure documents accessible is in how each document is maintained. What we have found is to be effective at maintaining accessible P and P documents is to separate policies and procedures.
What happens when you combine your Policy and Procedure in one file?
When you combine your policy and procedure into one document, it’s a lot harder to understand, as an employee what I need to do. Your policy section is primarily for managers to ensure their teams are abiding by organization-wide policies and that confuse policy with procedure.
Consider for a moment a very simple example of holiday pay.
The holiday pay policy has a list of approved holidays, guidelines for compensation and disciplinary actions if the policy is violated in one way or another. Essentially, the policy is giving managers a high level guideline as to what to enforce and look for when managing their team’s holiday time.
The holiday procedure, on the other hand, does discuss holiday pay. But rather focusing on the ‘what’, these procedures are underscoring the ‘how to’s’. There is a policy that provides staff steps to get approved time off for floating holidays. There is also a separate instructions on how to calculate worker pay that work the holiday shift. You probably will also see steps for compensating time off (this would be a distinct procedure).
Now what if all of these procedures—the floating holiday procedure, wage calculation procedure and holiday compensation procedures—were all stuffed within the policy? Would your staff reliably be able to find the information they need to successfully work during a holiday or use a holiday on a different day? Would anyone come to you with questions?
The more questions you have with P and P, the more likely your P and P could use some tweaking.
Now, holiday pay is probably a rather benign scenario. Think of all of the extremely serious situations where policies AND procedures need to be clear. What about for specific treatments? ER procedures? Security procedures? What if you had an emergency come into your facility and your team was searching for a procedure embedded within a policy? How much time would be wasted searching?
What are the chances the procedure gets missed because they end up just figuring it out?
Bottom line: if you combine P and P together, you’re making it harder on your team to find and access the information they need.
