Writing policies and procedures in healthcare

Healthcare policies improve operational excellence and patient care. Here's how to develop and manage policies that protect your organization.

December 22, 2020

Article highlights

Writing policies and procedures in healthcare can feel overwhelming. Whether you’re crafting an entirely new employee handbook, revamping existing procedures, or introducing new policies, it can be hard to know where to begin.

Policies and procedures are an incredibly important part of making sure your staff knows how to care for patients and do their jobs well. Policies provide the foundation for operational excellence and good patient care.

Importance of policies and procedures in healthcare

Policies and procedures in healthcare are far more than just general guidelines.

Policies and procedures set expectations and proper ways of doing things. They guide day-to-day activities, helping promote consistency in practices, reduce mistakes, and keep patients and staff safe.

Healthcare workers regularly deal with life-or-death scenarios. Having the proper procedures in place helps them make good decisions and provide the best possible care to patients.

Well written policies and procedures also protect your organization. They manage and mitigate risks by laying out procedures in detail.

If an incident were to result in a lawsuit, policies and procedures minimize liability by showing that your organization had proper processes in place.

Learn more about healthcare policy and procedure management in this free guide.

Before you begin writing policies

Writing policies and procedures in healthcare is tricky. There are so many different areas and tasks to cover – everything from patient care, to billing, to data security.

While you can’t create a detailed procedure for every possible scenario, you should try to make sure to cover all your bases.

Before you begin the writing process, set yourself up for success by taking a look at your current policies and laying the groundwork for a consistent, organized policy handbook.

Conduct a policy audit

First, try to get a broad overview of the current state of policy in your organization. What policies do exist? When was the last time they were updated? Do they line up with current technology and practices? Are they consistent with other policies? What policies are you missing?

Having contradictory, unorganized policies is not much better than having no policies at all. Sometimes, employees have abandoned following a procedure because it’s inefficient or doesn’t include the latest technology. Survey your staff members to find out what is working and what isn’t. Look for gaps in policy and procedures that haven’t been formalized.

As you do this, make a list of the policies that need to be updated first. Policies that cover common practices, high-risk tasks, and areas regulated by law should take first priority.

Create a standard policy format

The content of your policies matters more than how they look. But having a standard, well-organized policy structure helps make policies easier for employees to navigate.

Creating a standard format for your policies will help with consistency and ensure you include all the necessary information in each policy. It will make it easier to organize your policies and keep track of when they were last updated and what they cover.

Here are some things to include in your standard layout for policies:

  • Date
  • Policy Number
  • Applicable statutes or laws
  • Approvers
  • Procedures
  • Definitions
  • Examples

Use a policy management software like PowerDMS to create and update your policy template.


Appoint a policy team

Writing policies and procedures in healthcare shouldn’t just fall on one person’s shoulders.

In order to create the best possible policies, gather a team to help oversee the policy writing process. Many organizations have a compliance officer or team, which is a good place to start, but a policy team should go beyond this.

Bring in different perspectives by including people from different departments, especially if there are a wide variety of policies to update. Also look for some experts to ensure your policies comply with all the relevant laws and regulations.

Not every member of the policy team needs to participate in the actual writing process, but they can provide helpful input. Use PowerDMS’s policy management software to collaborate, gather notes, and track updates.

When it comes to actually writing policies and procedures in healthcare, it’s often helpful to appoint an “owner” for each policy. This person will be responsible for making sure the policy is regularly reviewed, revised, and distributed.

The policy writing process

Once you’ve established a policy team, determined what policies you need, and created a template, you can begin actually writing your policies.

The process will look different for every organization, but here are a few best practices for writing policies and procedures in healthcare:

Conduct thorough research and identify experts

In a high-risk, highly regulated industry like healthcare, it’s especially important to ground policies in laws and regulatory standards.

Healthcare policies should be customized for each organization. They should be tailored to the values and needs of your organization.

However, policies and procedures shouldn’t just be based on good ideas or hopeful outcomes. First and foremost, they should be based on existing laws and regulations.

As you’re writing policies and procedures in healthcare, make sure to thoroughly research laws and consult legal experts.

Larger hospitals or healthcare organizations may have legal experts available in-house or through industry networks. Smaller organizations or clinics can look to model policies as a good starting point.

Either way, keep in mind that requirements may differ depending on the size, nature, and location of your organization. Make sure to do your homework and create policies that work for your needs. Don’t simply copy and paste legal language, since the generic language may not be effective for your situation.

Review regulatory and accreditation standards

Many healthcare organizations pursue accreditation as a way to improve the quality of care and build trust with their community.

In order to achieve accreditation, your organization will need to meet a set of specific, strict, standards published by an accrediting body. This includes requirements for policies, procedures, and training.

Make sure you have those requirements on hand while writing your policies and procedures.

PowerDMS’s accreditation management tools can help you compare your policies with accreditation requirements to make sure you have the proper language and components to meet the standards.

List out procedure steps

Day-to-day tasks in healthcare tend to be much more complex and risky. If done wrong, even the most routine task can put a patient or staff member in danger.

Therefore, clear procedures are especially important in healthcare.

Healthcare procedures can be much more lengthy than those in other industries. So they need to be easy to follow.

When writing procedures, try to use clear, understandable language. Don’t try to guess at how things are done. Have front-line staff review the procedures to make sure they are practical, effective, and line up with best practices. Or see if you can shadow an employee to see how a procedure is done.

This process can help alert management to workarounds and hidden processes that employees are utilizing to get the job done.

If employees aren’t following proper procedures, you can identify why and course-correct. Perhaps the procedure is hard to understand or overly complex.

The employees who do the task every day may be able to help you identify a more efficient procedure that still complies with laws and standards.


Include measurable objectives

The most effective policies communicate the reasons behind the rules. Employees need to know that policies and procedures are not just arbitrary. Following the policies and procedures will help improve patient care and organizational effectiveness.

It’s helpful to include goals or objectives for each policy. Try to make these objectives clear and measurable.

For example, a hospital hygiene policy might include the objective of reducing hospital-related infections. Perhaps it includes the goal of reducing infections by 10 percent over the next year.

Establishing this goal allows management to measure the effectiveness of the policy. If infections have decreased, they know the policy is doing its job. If not, they can re-evaluate to figure out how to improve the policy and procedures or create a more realistic objective.

Use common, easy-to-understand language

Healthcare involves a lot of technical language, industry jargon, and acronyms. While medical personnel may understand these terms, other employees may not. And your policies need to be comprehensible to everyone on your staff.

As you’re writing policies and procedures in healthcare, strive to make the language as easy to understand as possible. This may take extra time and attention to detail, but it’s well worth it to avoid confusion and make sure everyone understands expectations.

If you’re having a hard time, ask non-medical personnel to read the policy to see if it makes sense to them.

Review policy drafts

Writing policies and procedures in healthcare is a process. Even the best written policies will need revising. And many policies will require inputs and sign-offs from upper management.

As you create policies, identify who needs to review them. Depending on the policy, this may include general counsel, medical directors, HR managers, compliance officers, the board of directors, or even the CEO.

Find a policy management software with a workflow feature that lets you automatically route the policy draft to the appropriate reviewers. With PowerDMS’s workflow feature, you can track edits, comments, and feedback all in one place. You can also send automatic reminders so the draft never gets lost in the process.


Putting policies into practice

Even the best policies won’t do much good if your staff never sees them.

After you’ve finished writing policies and procedures in healthcare, create a plan to implement and measure your policies.

Distribute policies and obtain employee sign off

Making policies and procedures easily accessible for all employees is a good first step in good policy management. Storing all your policies in one secure, centralized location, allows employees to easily find the information they need when they need it.

But healthcare employees are busy. New and updated policies and procedures can easily fall through the cracks and go unread and unheeded.

In order to ensure that employees understand policy updates, use a policy management software to gather employee signatures.

With PowerDMS, you can compare versions and highlight updates so employees can quickly spot what’s changed.

Train employees on the new policy

Training is an essential part of implementing policies and procedures. Training helps employees see how policies apply to them. It walks them through how to properly follow procedures.

Not every policy needs a training course, but many do. All training should be based on policies and procedures, so you may also need to look at your current training courses to make sure they are in line with updated policies.

Monitor policy compliance and effectiveness

As stated before, the best policies include measurable goals and objectives. This helps you determine whether policies and procedures are effective.

After you implement new policies, regularly monitor compliance and effectiveness. Are employees following the procedures? Are there notable violations? If so, what steps are being taken to remediate? Are the policies having the intended outcomes of improving patient care and safety?

Regularly asking these sorts of questions can help you continually improve your organization’s policies and procedures.

Set up a policy review cycle

Healthcare regulations and standards are constantly changing. Policies and procedures in healthcare should be living, breathing documents that grow and change with your organization.

Try to get into the routine of reviewing and updating policies at least annually. This will help you stay up to date with current regulations and best practices, and make sure your policies are effectively serving the needs of your organization.

Writing policies and procedures in healthcare is an incredibly important part of protecting your organization, improving patient care, and ensuring smooth operations.

As you craft policies for your organization, use PowerDMS to collaborate with your policy team, gather feedback, and distribute and track all of your critical policy content.

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