Eight Steps to Policy and Procedure Development
The development and implementation of policies and procedures is key to the successful operation of any Medical Staff organization. Policy governs the transition between the organization’s mission and its daily operation. Once an organization has developed a clear and concise policy and made it broadly available within an organization, it can create procedures and plans to carry out the organization’s mission.
Most Medical Staff organizations have written policies in one form or another. More often than not, these are out of date, inconsistent or not easily available to most of the organization’s employees. Some organizations also have tacit policy that is equally important to the successful management of the organization, and it should be written down as well.
The development of comprehensive Medical Staff policy and procedure manuals involves eight steps that form a sequence of compilation, review and organization.
Step 1 — Collect all documents that include or relate to organizational policy, including any existing policy manuals, board resolutions, staff memos, employee handbooks, or other documents.
Step 2 — Review the existing policy and quasi-policy for subject matter and key words. Create or refine a set of categories that reflects the needs of the organization. Then group this material by category.
Step 3 — Query medical staff management either individually or as a group to access any unwritten and undeveloped policy, as well as to evaluate the obsolescence of an existing policy. Policy makers should also interview non-management staff (either in person or by written poll) to determine any policy gaps or discrepancies.
Step 4 — Review existing policy, unwritten policy, and quasi-policy in each category to determine whether policies are redundant, if there are gaps in policy structure, if there are contradicting policies, and where policies cross categories and should be subdivided. Isolate “policies” that are actually procedures and set them aside for development of procedural manuals.
Step 5 — Draft new policies that address currently unwritten or undeveloped policy areas. Again, review existing and new policies within categories and across categories for consistency. Consult management to resolve questions about contradictions or gaps.
Step 6 — Reconstruct existing policies, revised policies and new policies to provide consistent, logical policy and procedure manuals complete with a table of contents and indexing. Completed policy and procedure manuals should include guidelines for future additions and changes.
Step 7 — Present completed policies to the executive staff, board, medical staff committees, or other appropriate bodies for approval and ratification.
Step 8 — The final stage in policy and procedure development is to produce a completed package in an accessible form, either in hard copy or as electronic documents, so that policies and procedures are readily available to those employees who will need them. Using an interactive database to access many policy and procedure manuals makes it easy to locate and cross-reference policies.
Note: This article originally appeared in the ProPell Group Newsletter. You can contact the ProPell at (503) 538-5030 or e-mail the company at info@propellgroup.com.
