Policy & Procedure Management 101

May 4, 2020 Polly Kirk

What exactly is policy and procedure management you ask? Simply put it’s the process of creating, communicating, and maintaining policies and procedures within an organisation.

A typical hospital has numerous policies on varied topics so an efficient policy and procedure management system is critical. A comprehensive and well-managed set of policies can support a healthcare organisation’s activities by communicating boundaries and expectations, establishing a culture of compliance within the organisation, protecting the organisation from litigation, and helping provide the best possible care to patients. It is a critical component of care in any healthcare institution.

The best practices to ensure that your organisation’s policy and procedure management is handled effectively and efficiently.

Find A Policy Administrator

This is key. The policy administrator is the person who will be the resident expert for your policy management system. This could be either a full or part-time position based on the needs of the organisation which can be sourced internally or externally. When hiring internally, healthcare organisations usually find a good candidate within the administration, quality, or compliance departments. Their responsibilities include maintaining and distributing policies, procedures and forms, providing training, and compiling policy data.

Create A Policy Committee

Time to rally the troops. Assembling a policy committee is an important best practice that will help keep your policy initiatives on track, policies up to date, and your organisation in compliance with regulatory bodies. Policy committees allow for centralisation of thought and open communication about your policy and procedure management process. The committee should consist of key stakeholders from various departments, including nursing, quality, administration, education and IT. You should meet a minimum of once a quarter to no more than once a week. Policy committee meetings should be tactical in nature, last no more than 50 minutes and have a clear agenda outlined.

Standardise Your Policy Format

Consistency is your best friend. Policy standardisation should be a major priority for healthcare organisations. Organisational changes, including merges and regulatory changes, can lead to inconsistent policy formats. It is best to achieve a consistent look and feel for your policies, with a corporate logo, an appropriate legal disclaimer and the inclusion of all key policy sections.

Create A Policy On Policies

Set the standard. Creating a policy on policies is an important step to having an organised and efficient policy library. Your policy on policies will set the process for drafting, reviewing, and approving all organisational policies. It should be written with regulations and standards, organisational norms and expectations and your policy management system in mind.

Delegate Responsibilities And Control Access

Establish a workflow. Your policy management system should allow you to delegate responsibilities to specific individuals such as writing, editing, reviewing and/or approving policies. Establishing committees and workflows will standardise the way a policy is revised each time. In addition, your administrators should have full control over granting users (or groups of users) different levels of access for reading and editing policies, thus increasing overall security and privacy.

Track All Policy Changes – When, Why And By Whom

Create accountability. A clear trail of policy changes is imperative when questions or disputes arise relating to compliance. An effective policy management system should track all changes and record who made each change, when it was made and why. Your policy management system should automatically notify the appropriate individuals when policies are up for review and archive previous versions.


An efficient approach to policy and procedure management is standardised, has designated leaders and provides easy access to all updated policies and procedures. A comprehensive policy and procedure management system should be a pillar of an organisation’s compliance and patient safety activities. In today’s ever-changing regulatory environment it is important to have a policy and procedure management system that can adjust and adapt to the needs of your organisation. These best practices will help your organisation form a solid foundation to reach your policy and procedure management goals.

Would you like more information on implementing a policy and procedure management system in your organisation? Contact us to see a full demo of our Policy Management Software.

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