1. Part II Objectives Describe how policies and procedures are used
Identify different types of P & P
Describe the purpose and components of a Policy on Policies
Explain the approval and review process for policies and procedures
Describe suggestions for writing policies and procedures

2. When to Write or Revise P & P
Starting new or when changes occur
When required by legislation/regulation
Policies must take into account various levels of legislation/regulation which impact health care delivery

3. When to Write P & P Examples:
Federal government establishes health care legislation and funding, e.g., Title X regs
State government takes action in accordance with Federal legislation, e.g., state statutes, admin. code, program regulations
Local government plans for mandated services and decides whether to offer non-mandated services. Decisions are made at several levels.

4. Use of P & P Administrators manage in accord with policies
Administrators design procedures to carry out policies
Examples
fiscal procedures
program protocols
purchasing procedures

5. When to Write P & P Examples cont’d:
Levels of decision-making:
Board of County Commissioners
Board of Health
Local Health Department/Health Director
Program Area
These decisions form the basis for policies and procedures

6. When to Write P & P Examples: Federal level--HIPAA, OSHA
State level--Nurse Practice Act, Bd of Pharmacy regulations, program policies
Local level--County ordinances, various county-wide policies
Agency level--P & P to carry out the work of the agency

7. Types of Policies and Procedures
Agency Policies
a broad description of what agency does and why
include the objectives, rules, and regulations which guide agency activities and direct allocation of resources
should be consistent with agency mission statement, strategic plan & community assessment

8. Types of Policies and Procedures
Program Policies
describe the what and why as they apply to individual programs
include the objectives and rules which direct a specific program focus and activities
should be consistent with overall agency policies

9. Types of Policies and Procedures
describe in detail how and by whom the work is to be done
should be consistent with policy statements
Protocol
the plan for processing patients through a given program
a treatment plan used by mid-level practitioners

10. Types of Policies and Procedures
Standing Orders
the framework for Registered Nurses to assess and treat disease while practicing in local health department settings
signed instructions of a physician which outline the medical assessment, appropriate testing, and treatment performed on behalf of the physician
standardize the clinical care practiced
require no medical decision-making by nurse

11. Policy on Policies
A policy that governs the policy development process
Describes the process used in your agency to develop policies and procedures
P on P should address the following components:
who initiates the process
who writes
format--type face, margins, headings

12. Policy on Policies Components, cont’d:
identification system, e.g., by name or number
organization system, manuals vs. stand alone policies, electronic, intranet, internet
writing style
approval process
review and revision cycles

13. Policy on Policies Components cont’d:
education and distribution
archiving
Sample Policy on Policies in handouts

14. Approval and Review Process
Policy on Policies should provide
direction on who approves policies
define review and revision cycles
Approval
policy should be signed by the individual approving the policy
date of approval should be recorded

15. Approval and Review Process
Review and revision cycles
may be the same for all P & P
may be different for groups or categories of
P & P
Recommend P & P be reviewed and revised as needed and at least annually

16. Policy Development Process
Suggested steps:
1. Define the issue, problem or task
2. Determine responsibility for writing
3. Involve all disciplines who will be affected and are involved in carrying out the program
4. Involve medical consultant when developing policies related to clinical services

17. Policy Development Process
Steps cont’d:
5. Use an agreed upon template or format
6. Write draft of the policy or procedure
7. Review and analyze the draft
8. Revise the draft as necessary
9. Do final review

18. Use of P & P
Boards adopt policies to guide the work of an organization
Boards govern by policy
Examples of policies adopted by Boards
fiscal policies
program policies
personnel policies

19. Policy Development Process
Steps, cont’d:
10. Make final revisions
11. Adopt the policy or procedure
12. Distribute policy or procedure
13. Educate staff

20. Policy Development Process
Steps, cont’d:
14. Implement the policy/procedure
15. Conduct on-going evaluation/revision per policy on policies

21. Policy Development Process
REMEMBER:
Some policies should be reviewed by:
County Attorney
County Manager
Personnel Officer
Medical Advisor
Other as appropriate