The Key to Writing Policies and Procedures Updated: February 2012 Public Health Nursing & Professional Development Unit Eunice Inman, RN Gay Welsh, RN Pamela Serrell, RN Ellen Shope, RN Lynn Conner, RN

Objectives: Part I Define the differences between policies, procedures and standing orders List the content of a policy, procedure and a standing order Define tips on technical writing for policies and procedures Identify resources for writing policies and procedures

Definition = Policy A course of action adopted by and pursued by an agency that guides and determines present and future decisions and actions. Policies indicate the general course or direction of an organization within which the activities of the personnel must operate. (The American Correctional Association) Policy = should reflect a broad intent and goal.

Definition = Policy It is a tool that helps employees attain agency goals - “what” and “why” of the goal or intent of the agency. A policy will denote the what and why of the goal.

Definition = Procedures The detailed and sequential actions that must be executed to ensure that a policy is implemented. It is the method of performing an operation or a manner of proceeding on a course of action. Procedures give a METHOD for carrying out a policy. Procedures are action oriented.

Definition = Procedures It differs from a policy in that it directs action required to perform a specific task within the guidelines of the policy. (The American Correctional Association) Describes the “how, who, when or where” through which policies are carried out. Procedures denote the how, when or where of how the policies are carried out. When procedures are written to support policies, you will have the who, what, where, how, when and where.

Definition = Standing Orders “Standing Orders” (SO) are defined as, “the signed instructions of a physician which outline the medical assessment, appropriate testing and treatment that a clinician may perform or deliver on behalf of the physician.” SO serve to standardize the clinical care practiced by all clinicians. SO are written instructions prepared by a MD and designed for a patient population with specific diseases, disorders, designated health problems and/or sets of symptoms. Delineates under what set of conditions or circumstances actions should be taken.

Definition = Standing Orders SO provide the framework to assess and treat diseases while practicing in LHDs. SO allow RNs to determine, based on parameters identified in the SO whether a specified condition exists, thus indicating the need to execute the order. SO are written instructions prepared by a MD and designed for a patient population with specific diseases, disorders, designated health problems and/or sets of symptoms. Delineates under what set of conditions or circumstances actions should be taken.

Definition = Standing Orders SO may NOT call for the RN to discriminate assessment findings beyond the level of normal vs. abnormal. SO are written instructions prepared by a MD and designed for a patient population with specific diseases, disorders, designated health problems and/or sets of symptoms. Delineates under what set of conditions or circumstances actions should be taken.

Reasons for Policies & Procedures Translate mission statement into practical terms Shapes the behavior of personnel - providing consistency in agency practice Protects patients and employees Supports accreditation Provides legal protection

Contents of Policies Header contains: Title Policy Category and/or Number Approved By Effective Date Revised Date Affected Program Area(s) Headers may be as simple or as detailed as needed. Agencies may opt out of using a numbering system or listing the affected program areas. The other components are necessary.

Contents of Policies Purpose Statement = Scope states the “why” Definition(s) = clarifies/standardizes terms Responsibilities = “who” does it Policy/Procedure = “what” shall be done Legal Authority = applicable laws/rules Reference Policies/Procedures = other policies/procedures with similar content

Contents of Procedures Subject Objective or purpose of the procedure Equipment needed Responsible person Patient preparation and teaching Action steps SO are written instructions prepared by a MD and designed for a patient population with specific diseases, disorders, designated health problems and/or sets of symptoms. Delineates under what set of conditions or circumstances actions should be taken.

Contents of Procedures Documentation Referral and follow-up Additional information Legal, ethical considerations Appendices Note: Components may vary depending on the type and nature of the procedure SO are written instructions prepared by a MD and designed for a patient population with specific diseases, disorders, designated health problems and/or sets of symptoms. Delineates under what set of conditions or circumstances actions should be taken.

Tips for Writing P & P 1. Use active voice, present tense 2. Clearly identify the level of priority 3. Use standard word order - subject-verb-object 4. Be consistent 5. Use short words and acronyms 6. Use common words These tips are adapted from Writing Effective Polices and Procedures by Nancy Campbell. Use a step by step sequence. Use the clearest/shortest sentences to convey the process.

Tips for Writing P & P 8. Use short sentences and paragraphs 9. Use lists 10. Use few words and avoid redundancies 11. Watch out for problem words and jargon 12. Remember the rules for readability In procedures, use one action per step, starting with the verb and then assign the action. The readability level should be on an eight grade reading level.

Template This is a basic template that you will see in some of the sample policies from LHDs who have been accredited and in the articles we have included as hand-outs.