Healthcare health and safety policy (with free template)

In a high-trust organization that frequently deals with life and death situations, workplace policies and procedures create a safe foundation.

August 11, 2021

Article highlights

Over the past year and a half, the importance of workplace safety in the healthcare industry was a constant source of news, as medical professionals made every effort to stay healthy during the ongoing fight against the pandemic. 

But workplace health and safety is critical in the day-to-day operation of a medical facility, pandemic or not. Healthcare workers face a variety of risks, from injury to illness. And while much focus goes to the personal protective equipment that keeps them safe, there’s another key aspect to a healthy workplace.

This work truly starts with health and safety policy. Your workplace health and safety policies and procedures are the guidelines that inform the work done by your staff, giving them a rulebook for what to do, and how to do it safely.

They’re part of the overall network of policies that improve consistency, help with compliance, and maintain safety within a health care setting. See examples of other types of healthcare policies here.

As a leader within a medical facility, you face a lot of demands on your time and resources. Developing a health and safety policy manual is a significant task, but it’s one that will be well worth it in the long run. Having strong policies and procedures allows you to be more efficient when it comes to compliance and accreditation, and it offers protection against legal liability.

In this article, we’ll examine the role of policies and procedures in healthcare in detail, and then offer guidance as you embark upon crafting your own.

The importance of health and safety policy in healthcare

When medical care professionals go in to work each day, they face a high-pressure and potentially dangerous environment.

Healthcare is the most dangerous industry in studies of injuries and illness, with staff members facing exposure to disease, accidents, and attacks from patients. This is obviously damaging for those affected workers, and it also has significant impacts for organizations.

“The American Federation of Labor and Congress of Industrial Organizations (AFL–CIO) reports workplace violence causes businesses to lose an average of $250-$330 billion annually due to loss of productivity, illness, injuries, turnover, lawsuits, absenteeism and a loss of customers as a result of a damaged reputation.”

The costs include workers’ compensation for lost wages and medical costs, paying for temporary staffing, turnover costs when an injured employee quits, and decreased morale and productivity.

This is a significant enough issue that the Occupational Safety and Health Administration (OSHA) created a web page for healthcare safety resources

Potential hazards faced by healthcare workers include lifting and moving patients, needlesticks, slips and falls, and the potential for combative patients and visitors. Trained to “do no harm” to patients, workers will sometimes put their own safety at risk to take care of a patient.

Such injuries and fatigue also can put patients at risk of dangers including medication errors and patient infections.

Safety issues across medical facilities

A strong health and safety policy is important for any medical facility, even those with less intense environments. Every workplace has its own challenges and potential dangers. 


A hospital is a busy, dynamic setting with the potential for emergency around every corner. A workplace health and safety policies and procedures manual needs to encompass all of the work that happens here, from daily tasks to special circumstances.

From ASCs to laboratories, skilled nursing facilities, and more, a variety of facilities can fall under a hospital’s purview. Your health and safety policy manual will need to be created with each in mind, or even better, a separate policy will need to be created to address each facility’s unique health and safety challenges.

Ambulatory Surgical Centers

Surgical centers are some of the most high-pressure settings within healthcare. Workers face complicated tasks, and contamination is a serious concern. 

ASCs are also highly regulated and often have smaller budgets, meaning you may have to accomplish more with less money and less staff. Policy management software can help streamline your processes, so you can stay in compliance and feel confident that employees can easily access policies and procedures at any time, from any device.

LTAC and Assisted Living

Staff have a great deal of interaction with patients and visitors at long-term care facilities, which brings the potential for injury or the spread of illness. At the height of COVID, patients within these facilities were at high risk, and your staff’s diligence to health and safety policies and procedures helped save patient lives.

Student Health Centers

Primary care facilities like student health centers bring their own challenges and take special focus to ensure best outcomes for students, all while keeping staff members healthy. At the onset of the pandemic, before universities closed, student health workers were at risk, given their exposure to large student populations living and attending classes in close proximity to one another.

How to develop a health and safety policy

You’re convinced that you need a health and safety policies and procedures manual. Now it’s time to take on this work. But rather than simply jump into it, it’s important on the front end to do some planning to make the process as easy as possible.

First, think about what you’re creating. It’s a series of documents that cover three core areas, according to this Health and Safety Authority report:

  • Hazard Identification
  • Risk Assessment
  • Controls

Hazard Identification

Hazards are things that cause harm, either mental or physical. Your top priority are those hazards that can cause the most harm to the most people.

To identify these hazards, start by moving through the facility and look for those things that potentially could cause harm. A tripping hazard is one example.

Once you have your list, the next step is to talk to employees or representatives. They will have noticed things that you haven’t.

It also can be helpful to reach out to professional organizations relevant to your practice area. Often, they have existing standards and best practices. And those professional guidelines are often looked at as the highest standard in legal situations, such as malpractice cases.

In looking at equipment and chemicals, refer to manufacturer information, which should spell out hazards and will provide information on safe work practices.

Refer back to a history of work-related accidents and employee ill-health efforts to identify past hazards. While your focus will mostly be on acute hazards, don’t forget to look at long-term health dangers, such as prolonged or repeated exposure to chemicals.

Hazards fall into these key areas:

  • Physical, such as using poorly maintained equipment, or slips and falls.
  • Chemical, such as cleaning agents or medical gases.
  • Biological, such as viruses and bacteria that cause illness or infection.
  • Human factor, including issues that cause sustained stress and aggressive behavior.

Lastly, consider with each hazard who might be harmed and how. What categories of staff will be exposed to the hazard, as well as patients or members of the public. In thinking through this, make considerations for those who have increased vulnerability, such as pregnant women or those with different abilities.

Risk assessment

This step involves analyzing the probability that someone will be harmed by each individual hazard, while factoring in the severity of the potential harm. Ask these questions:

How likely will it be that a hazard will cause harm? How severe would that harm be? How many people would be exposed? Are there any control or protection measures already in place?

Answering these questions creates the risk assessment, which must be put into writing to form a safety statement. This is the informational base of your health and safety policies and procedures.


As a last step, consider what new controls need to be added to prevent harm around these potential hazards. Compare your risk assessment to the safety measures already in place and use it to decide whether these are adequate.

As an employer, you are legally required to do all that is reasonable to minimize health and safety hazards. When beginning to develop controls, look for the most urgent issues and take corrective actions around those first. Can you remove a hazard, or do you need to create controls around it?

Remember that there are specific regulations related to risk assessment for things such as manual labor and patient handling, hazardous chemicals, biological agents, display screen equipment, and pregnant employees. 

Controls also include the instructions provided to employees around risk mitigation. And as a final step, you need to share this health and safety policy manual with your employees, so that they are aware of the risks and precautions in the workplace.

Keep in mind that you will need to review regularly and make updates as needed. These will reflect changes to the workplace that could introduce new hazards, as well as changing federal standards and laws.

It’s also important to measure your performance, checking safety against compliance with legal standards. This review helps make certain that you are living out the policies you’ve established.

Creating policies is a team effort

In the work of building out these health and safety policies and procedures, keep in mind that you don’t need to do it alone.

You should consult with employees and safety representatives on staff who have knowledge of the work that goes on and the potential issues. You can also bring in an external adviser, but you should make sure that person has sufficient understanding of your operation.

You can also look at samples from other healthcare providers. In this health and safety policy example, you can see how Mercy Hospital approached this work.

As an employer, you’re responsible for your employees with regard to safety, health, and welfare at work, and you must provide them with certain information on these matters, including the results of risk assessments.

Employees also bear responsibility. Once policies are in place, it is their responsibility to adhere to those procedures to maintain a safe workplace.

Putting your health and safety policies into action

As you develop your health and safety policies and procedures, it’s key to make sure they aren’t simply documents filed away somewhere, but that they become a living part of the daily operation of your organization.

To do this, it can help to have a policy management software that allows you to distribute your policy to employees wherever they are. The cloud-based PowerDMS service does this and far more. To see what types of healthcare entities can benefit from PowerDMS, read this article.

For more help in policy writing, we’ve created this guide, How to Write Effective Policies. You can also refer to this health and safety policy template. We hope these resources help you in completing this critical work for your organization.

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How to write effective policies

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