DEVELOPING POLICIES AND PROCEDURES

Overview

In 2005 legislation was passed and state rules were adopted making local health department accreditation mandatory in North Carolina. Policy Development is one of the three core functions assessedfor determining a local health department’s capacity to perform the essential services of public health and to meet accreditation standards. A policy is an agreed-upon course of action for handling a specific set of circumstances. Policies must take into account various levels of legislation/regulation which impact health care delivery. For example:

  • Federal government establishes health care legislation and funding
  • State government takes action in accordance with federal legislation
  • Local government plans for mandated services and makes decisions regarding participation if services are not mandated. The local government decisions may be made at several levels:

--Board of CountyCommissioners

--Board of Health

--Local Health Department Director

--Program area

In addition, there are other related legislation/regulations to consider when developing policies. For example:

  • North Carolina Board of Nursing regulations regarding licensing and nurse practice, Nursing Practice Act
  • OSHA regulations
  • CLIA regulations
  • Board of Pharmacy regulations regarding dispensing of drugs

Purpose of Written Policies and Procedures

  • To provide a way to prove a standard of care
  • To affect safe practice
  • To affect accountability
  • To inform staff of the components of a quality assurance and improvement program
  • To establish staff expectations of self and others
  • To provide a framework for consistency in methods of practice
  • To set procedural standards of practice

Types of Policies and Procedures

Administrative Policies

  • A broad description of what the agency does and why.
  • Includes the objectives, rules, and regulations which guide organizational activities and direct allocation of resources.
  • Should be consistent with agency mission statement.

Program Policies

  • A description of what and why as they apply to individual programs.
  • Includes the objectives and rules which direct a specific program focus and activities.
  • Should be consistent with overall agency policies.

Procedures

  • Detailed description of how and by whom (discipline/position) the work is to be done.
  • Should be consistent with policy statements.

Accreditation Requirements for Policy Development

The North Carolina Local Health Department Accreditation program (NCLHDA) requires each LHDto adopt a standard practice for the development, review and revisionof policies and procedures. The agency determines the written format for their policies and procedures; develops and adopts awritten policy and procedure. This Policy on Policies then guides agency policy/procedure development, written format, approval process, review, revision, and access/training of affected staff. Mandated activities for accreditation within the Health Department Self Assessment Instrument (HDSAI),found on the website overall policy/procedure development include:

  • Activity 15.2: The local health department shall develop and adopt program policies and procedures that meet the following criteria:

---refer to the federal and state legislation, rules or regulations, or local rules or ordinances that provide the authority to carry out agency programs and activities, and

---delineates desired outcomes.

  • Activity 15.3: The local health department shall have a written procedure providing for annual review, and revision if necessary of all policies.
  • Activity 31.1: The local health department shall develop and implement policies and procedures regarding the administration of the local health department and shall assure policies and procedures are accessible to staff.

Once an agency policy for developing policies/procedures has been written and approved and a format/template determined, all agency policies should be in the designated format as they are initiated or revised.

Suggestions for Developing an Agency Policy on Policies

  • Utilize a multi-disciplinary team approach for determining content, formatting, categorizing (e.g., Administrative, Board of Health, Programmatic) and cataloging(e.g., grouped by category and policy number or title) agency policies. Hard copy manuals and/or electronic access decisions should be explored. Several factors may be considered in deciding the method of categorizing and cataloging the agency policies including the size of the workforce, services provided and agency IT capacity.
  • Determine who needs to review and approve policies/procedures. Some policies/procedures should be reviewed by the CountyAttorney, CountyManager, Board of Health or Medical Director/Consultant. Each agency is to make that determination and seek appropriate review and approval.
  • Develop a template for the selected policy format and make it available for staff designated to write policies.
  • Include in the header or footer the policy title, category and/or policy number, approval signature/s, effective date, revision and review dates, page numbers and file locater.
  • The Policy on Policies shouldoutline the policy and procedures for agency policies including:

---defining the categorization and cataloging of policies/procedures

---defining who (discipline/role) is responsible for developing and approval of

each category of policies/procedures

---defining standard content requirements for policies/procedures

---defining the procedurefor development and method/s used for notifying or

training affected staff on new or revised policies/procedures

---defining the procedure for assuring annual review of all policies/procedures

---defining the procedure for staff access to policies/procedures

---defining the procedure for archiving outdated or revised policies/procedures

  • All policies should contain a policy statement and a purpose (delineating the desired outcome).
  • All policies should reference the legal authority for the policy if relevant, e.g., statute, rule or regulation.
  • Including references to other related policies/procedures or guidance documents is recommended

Suggestions for Writing Policies and Procedures:

  • Include all disciplines of the health care team who will be affected and who are involved in carrying out the program.
  • Involve the Medical Director/Consultant when developing policies and procedures related to clinical services.
  • Follow the agency format template including all designated format headings; depending on the type and nature of the policy/procedure all template sections may not be needed; indicate “Not Applicable” when relevant.
  • Write in understandable, straightforward terms in sequentially logical order, and state clearly what is to be done, why it is to be done, who does what, how and when it is to be done. Include regulatory and supporting references as relevant.
  • Date each page.

Review and Revision of Policies/Procedures:

Agency policies and procedures should be signed and dated by individuals designated by the agency, at time intervals also designated by the agency, but at a minimum annually. The frequency depends on the nature of the policy, changing regulations and technology, with some requiring more frequent review than others. When revisions are made, the revised policy is be dated and signed by the appropriate individual/s designated by the agency and distributed to all individuals affected by the policy. Policies/procedures should reflect all revision dates and per agency policy may reflect what areas were revised.

Disposition of Outdated or Superseded Policies/Procedures:

When policies are revised or no longer applicable, an original of the outdated copy of the policy is to be retained in the Agency by a designated person. Retention of old policies/procedures should be in accordance with Local Health Department Records Retention and Disposition Schedules. A current document can be accessed online at under the link County and Municipal Records. The website includes additional records management guidance and contact information for regional records analysts and the Government Records Branch of NC in Raleigh.

NOTE: Despite the recommendations cited above for the disposition of “superseded policies”, health departments may wish to keep an archive copy on paper, microfilm, or disk, in accordance with agency policy,in order to be able to supply documentation of the standard of care at the time the care was delivered in the event of litigation occurring after a policy has been revised.

Policy Manuals:

It is recommended that an Administrative or Agency Manual be maintained for policies that are Health Department-wide, and that Program Manuals contain only policies which are specific to that particular program.

Resources for Developing Policies and Procedures:

PHN Consultants in the Public Health Nursing and Professional Development Unit work closely with local Health Departments as they prepare for accreditation. Much of this work focuses on assisting agencies to develop a standard for policies and procedures, sharing best practice examples and reviewing policies/procedures for the required accreditation components. Ongoing consultation is also available as needed from this group of regional consultants as well as from regional program area consultants. Many of the specific program areas branches have developed sample policies/procedures that are available to local agencies on the program websites.

Contact your regional PHN and/or program consultants for assistance as needed.

Sample Policy/Procedure Template

Three Part Power Point Presentation: Developing Policies/Procedures

  • Policy/Procedure Training ppt 2005; rev. 2012
  • Policies/Procedures Part II
  • Policy Management

PHN Manual2012