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While a “Policy on Policies” may sound a bit bureaucratic, having a policy that outlines the process for policy, procedure, plan, and guideline creation, review, and management will provide the information required for consistency and adherence to your document management process.
There should be areas of content in the policy to provide all the information needed for anyone involved in document management to effectively and consistently perform their responsibilities within the scope of your organization. It is important to be specific under each area of content to define action steps to providing what is necessary and what the organization process involves.


Definitions of Types of Documents
How does your organization define a policy, procedure, protocol, guideline or plan? If you don’t already have definitions outlined, here are some suggestions to consider.

Policy: A concise set of statements that communicate a pre-determined and definite course of action, expectations, and objectives enforced by the governing body and/or management. Policy statements and expectations are not flexible, do not allow for individual latitude, and require full compliance.

Procedure: The fixed step-by-step sequence that provides the instructions necessary to carry out a policy statement.

Patient Care:
A detailed plan concerning the actions of those involved in patient care/treatment, administration or medical research. A standardized course of medical treatment that has been approved by Medical Staff Committee(s) and/or other appropriate clinical committees. A physician’s order is needed to start a protocol (e.g., heparin, insulin).
Other: A set of conventions governing the treatment and especially the formatting of data in electronic communications systems (e.g., network protocols).

Guideline: A document or instructional guide that provides general direction or a course of action in a specified situation for how to accomplish a process (e.g., critical care guidelines). A guideline allows some discretion or leeway in its interpretation, implementation or use.

Plan: A written account of a future course of action with specific goals for achievement. Plans provide details of what needs to be done, when, how and by whom (e.g., emergency operations plan, infection control plan, strategic plan).

Definitions of roles and responsibilities in the organization P&P process and/or software
          Document Owner/Author: who is responsible for the content and maintenance of the document. This should be a subject matter expert rather than a higher level staff member who is responsible for formal approval of the document.
          Approver(s): the persons responsible for the formal approval of the document. These can be individuals and/or committees.
          Policy Administrator(s): the person or persons responsible for the oversight of the P&P process and/or software. Many healthcare organizations are now developing Policy Management Offices (PMOs) with a Policy Director and administrative staff to assist owners and approvers in adhering to the organization and regulatory requirements and audits for policy and procedure development and management. The PMO is also responsible for ensuring compliance with the organization processes.

Procedures for reviewing or changing current documents and creating new ones
Review intervals for documents
Necessity of new documents
Title naming conventions
Identification of document owner
Policy area and/or categorization
Approval workflow
Review Date
Scope and applicability
Education requirements and timelines
Process for changing document ownership and/or approvers

Required fonts and formats
It is important to clearly define the fonts and formats that are required by your organization. Several areas that are critical to consider when selecting fonts are:

How will staff be reading documents? If staff are reading documents in paper form in binders define the font and formats and provide a template in whatever word processor you use and margins that are required for them to be placed in binders. If staff are reading documents electronically certain fonts and formats should be avoided. Unfortunately, word processors give many options for fonts and sizes and formatting. The most ideal option is to utilize a policy and procedure management software system that defines and sets the font and format so that staff writing the documents will not be able to select fonts and formats that are difficult to read. If you are not using software or your software still allows for your writers to select their own font and formatting, it is important to define your requirements in your policy on policies and monitor them. To minimize eye strain, select sans serif fonts or those with minor serifs. These are easier to read on a computer. Other fonts, such as the Arial family, do not have a true italic option, which takes away options for emphasis.

What devices and/or web browsers will staff use to access documents? Keep in mind the type of devices your readers will be using for reading your documents. Even if they are reading them electronically and your software allows them to be accessed from multiple devices, all screens are not created equal. Remember that tablet screens and smartphones are very small screens so if a document is extremely long there will be a lot of scrolling involved. Instead, shorten your documents by hyperlinking to other documents or websites

Addressing regulatory standards
For specific document types always include the types of regulatory standards that should be considered
Provide links to regulatory websites for specific document type

Education processes
Outline education processes for documents and or groups of documents before publishing
Provide a template for documenting education processes
If the software allows for it insert an education step in the workflow of the document to insure it is fulfilled before publishing if required

Contact information for support resources
Provide the contact information for support resources in your facility
Policy Management Office (if you have one)
Policy Administrator
IT or help desk
Vendor contact information
Provide process by which to escalate an issue or question
Provide links to training resources
Vendor Site

Additional Attachments
Visual workflows for your approval processes
Copy of template/templates with checklists outlining required fields in the templates
Checklists for various staff roles to refer to and ensure everything has been completed in their area of responsibility

Other tips for policy development and management:

Simplicity and readability. Health care providers are busy and don’t have extra time to read through policies and procedures. Make policies and procedures simple to locate and write them with your employees in mind.

Use employee feedback for policy changes. Caregivers read policies and procedures on a regular basis, and those employees can provide feedback on what language is confusing or how policies can be more accessible.

Updating regularly for accuracy. Since health care workers are working at a fast pace, they are looking for the most direct route to the answers. If they find ambiguity within the policies, they will quickly stop trusting the documents as the primary resource for locating answers and turn to less reliable and inconsistent resources instead.

By providing guidance and structure to your policy and procedure development and management as well as providing clear, easy to access and easy to read documents for your busy staff, you can reduce your liability and increase the patient quality of care.

For more information, please contact:

Nita Bowers PhD

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