How to write policies and procedures in healthcare

What are policies and procedures in healthcare?

In healthcare, knowing what to do and when can be a life-or-death necessity. That’s why having well-written, thorough policies and procedures in every healthcare system is critical.

Policies and procedures outline expectations and define the proper way of doing things in certain scenarios.

Having these types of guidelines offers support for staff members and patients, empowering the healthcare workforce to be confident in handling emergencies and giving the best possible care to patients.

Why policy and procedures are important in healthcare

Not only do these documents provide direction for staff, but they can also help protect healthcare organizations from legal liabilities and manage and mitigate risks by outlining a list of procedures in detail.

If an incident occurred that led to a lawsuit, for example, policies and procedures can minimize liability by proving that your organization had proper processes in place before the incident.

Let’s face it – the healthcare industry is all too often the host of complex legal landmines, and having the right documents in place is critical in protecting your organization.

Writing hospital policy and procedures

Writing policies and procedures can seem like a daunting task, but it doesn't have to be. By following these tips and having the right tools in place to guide you, you can be sure that your documents will be clear, concise, and easy to follow. While the process might look different based on your organization, here are four things to consider when writing them:

1. The audience

Policies and procedures must be written in a language that can be understood by all staff members. Jargon should be avoided.

2. The purpose

Every policy or procedure should have a specific purpose. It should be clear what the document is trying to achieve.

3. The format

Policies and procedures can be long and complicated. To make them easier to read and follow, they should be clearly organized and written in a step-by-step format.

4. The review process

Policies and procedures should be reviewed on a regular basis to ensure they are still relevant and up-to-date.

What to do before you write policies and procedures

1. Understand the current state of policies

The initial step is figuring out the current state of policies within your healthcare organization. Are you starting from scratch, or are there current policies in place that need to be updated? Do they align with current technologies in the organization? Is it consistent? What is missing?

It’s critical for policies to be consistent, clear, and thorough. Dig through what is currently there and make a list of any gaps that are missing, or any inconsistencies. Talk to staff members to get a good idea of which policies are working and which are not.

2. Create a standard policy format

The organization and structure of policies are more important than you think, so think through it thoroughly. Having a format that’s attractive and easy to digest not only makes the reader’s life easier but also allows you to stay organized as you keep track of where policies were last updated and what they cover.

3. Appoint a team

Conducting policies and procedures is a tall task and should involve multiple experts and writers. A good place to start is to appoint a compliance officer or team and bring in multiple different department heads and experts for their input.

4. Research is key in every step

To truly understand the best policies and procedures for each organization within the system, extensive research needs to take place on current laws and regulations, the building structure, how teams operate, current safety measures, and more.

5. Involve experts

Make sure you include legal experts, safety experts, department heads, and other stakeholders in the organization that can give you insight into how teams run, what’s working and what isn’t, and what to consider from a legal and safety perspective. It’s also a good idea to shadow members of the organization to see how things are currently done.

The writing process for healthcare policies and procedures

1. List out step-by-step procedures.

In healthcare, even simpler tasks tend to be riskier and more complex than in other industries. That’s why it’s so important to list out procedure steps as clearly and thoroughly as possible to avoid confusion. Limit jargon and confusing, lengthy language as much as possible and instead use plain, easy-to-digest language.

2. Include measurable goals for each policy.

For employees to get on board with the policies and believe in their effectiveness, it’s helpful for them to see the goals and objectives for each one. For example, one goal could be to reduce hospital-related illness by 15 percent in one year. A goal like this helps the staff know the reason behind what they’re doing and helps them stay motivated to work towards achieving it.

After drafting policies and procedures

1. Review each draft

Writing policies and procedures is no small feat – it often takes a lot of time, research, planning, and creating multiple drafts until the final result is reached. As you are drafting policies, continue to partner with experts, human resources (HR) managers, general counsel, and leaders in the organization to review and approve them.

2. Prioritize employee training

The primary reasons for having policies and procedures in place is for the staff to learn them and adhere to the rules to prevent hazards and to give patients the best care. That said, it’s critical that employees complete trainings.

3. Monitor policy compliance and effectiveness

Over time, monitor and track the effectiveness of the new policies by measuring your goal metrics. Are employees adhering to the new policies? Are the policies serving their purpose? Have there been any hiccups along the way that you need to adjust? Keep in mind that even when you have completed a “final” draft of the written policies, they should continuously be updated.

4. Set up reviews regularly

To make sure the policies are serving their purpose, continuous research is necessary. Set up review cycles with department heads, legal counsel, and other experts to ensure the documents are up to date on all current laws and are efficient and thorough.

Effective policy and procedure management

Ensuring your organization’s policies and procedures are up-to-date and widely accessible is a tall task – but Healthstream can help you track, manage, and distribute documentation confidently. Learn how you can leverage Policy Manager to search and access documents with ease, enhance policy workflow and automation, and secure attestation and quizzes.

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