Policies and Procedures in Healthcare

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‘Policies and procedures’ is the first component of Patient Safety and Quality Systems, as outlined by the Australian Government’s National Safety and Quality Health Service Standards  (NSQHSS).

Patient Safety and Quality Systems

Purpose: Patient safety and quality systems are in place within governance processes to allow organisations to advance the safety and the quality of patients’ care (Australian Commission on Safety and Quality in Health Care 2017).

Policy v Procedure: What’s the Difference?

Policies and procedures are the first things an organisation should establish in order to operate effectively. Policies are rules, guidelines and principles that communicate an organisation’s culture, values and philosophies (Kenyon 2018; Business Dictionary n.d.).

Policies include:

  • Employee entitlement and what they can expect from the organisation;
  • What the organisation expects from their employees;
  • What consumers and the community can expect from the organisation.

Procedures provide step-by-step instructions for routine tasks. They should also allocate people to be responsible for certain tasks. Procedures should make it clear which steps should be taken in common scenarios and who should be reported to. A checklist may be involved (Kenyon 2018).

Procedures may include:

  • Handling complaints;
  • Documentation and handling healthcare records;
  • Managing patient aggression.

Policies and procedures are fundamental for consistency across an organisation, for both staff and consumers. They guide the organisation, influencing and determining all major decisions and actions, and reduce liability risks (Kenyon 2018).

Policies and procedures should be widely accessible and cover all activities carried out by the organisation. All policies should be laid out in the same format and should be written in common language that all staff members can comprehend (Gasior 2017).

The Quality Systems planning process may involve steps such as:
  • Establishing a policy team or group;
  • Identifying possible conflicts of interest;
  • Engaging with stakeholders;
  • Engaging with consumers;
  • Engaging First Nations Peoples and diverse groups;
  • Analysing purpose and context;
  • Define the scope of the policy or procedure;
  • Alter, adapt or start from scratch;
  • Investigate:
    • Transparency;
    • Implementability;
    • Equity.

(NHMRC n.d.)

The implementation of a new policy should be followed by this process, at a minimum:
  • Distribute policies and have all employees sign them;
  • Ensure that staff are all trained on the new policy;
  • The compliance and effectiveness of policies should be monitored;
  • A policy review cycle should be established.
  • (Gasior 2017; NHMRC n.d.)

    Policies and Procedures in Healthcare

    Policies and procedures are an incredibly important part of making sure staff know how to care for patients and how to carry out tasks with confidence. Policies and procedures provide standardisation in everyday operational activities, which helps to foster consistency in practices, decrease mistakes, and keep both patients and staff safe (Gasior 2017; Leahy n.d.).

    The NSQHS Standards outline that a health service should manage risk in the following ways:

  • By reviewing the effectiveness of policies, procedures and protocols.
  • By taking action to improve adherence to these systems.
  • By reviewing compliance with legislation, regulation and jurisdictional compliance.
  • (Australian Commission on Safety and Quality in Health Care 2017)

    Policies and procedures are particularly crucial in healthcare as it is an industry that is very familiar with crisis; healthcare organisations endure a high rate of liability risks. When appropriate policies and procedures are in place, an incident is easier to navigate (Kenyon 2018).

    This is because procedures outline the actions that an employee and manager should take when an incident occurs. Additionally, reviewing policies, procedures and incident reports may help those in leadership positions to identify what went wrong and prevent them from reoccurring (Kenyon 2018).

    Policy and Procedure Review

    It cannot be overstated that policies and procedures must be constantly reviewed and updated. Healthcare standards and regulations are constantly fluctuating. At a minimum, these documents should be refreshed annually and each time a new law or regulation is put in place or updated (Gasior 2017; Leahy n.d.).

    Patient Involvement

    In recent years the notion of patient involvement in reviewing policies and procedures has gained traction. Both clinical and non-clinical committees should regularly review all policies and procedures, according to recommendations by The United States-based Institute of Medicine 2011 Standards for trustworthy clinical practice guideline development (Armstrong et al. 2017).

    Patient involvement is a relatively new concept and is yet to be embraced completely. This could be viewed as an opportunity wasted. Patient and public contributions to policy and procedure development can include:

    • Evaluation of guideline priorities;
    • A re-focus towards holistic approaches to care;
    • Broaching new topics;
    • Identification of populations and outcomes;
    • Suggestions as to whether findings are meaningful or relevant;
    • Determining how or to what extent recommendations interact with patient values; and
    • Prompting the use of common-language within these documents.

    Together, policies and procedures help to ensure that the ethos and vision of a health service organisation are communicated into tangible steps that lead to the outcome of safe, high-quality healthcare.

    Additional Resources
    • Australian Commission on Safety and Quality in Healthcare 2017, National Safety and Quality Health Service Standards, 2nd Edition: https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-Quality-Health-Servi ce-Standards-second-edition.pdf
    Multiple Choice Questions Q1. True or false: Employee entitlements should be covered by an organisation’s policies.
  • True
  • False
  • Q2. Policies and procedures should be updated when?
  • Annually.
  • When a new law or regulation is introduced.
  • When it uses language that reads as outdated.
  • All of the above.
  • Q3. True or false: New policies should be signed by all staff.
  • True
  • False
  • References
    • Armstong, M and Bloom, J 2017, ‘Patient Involvement in Guidelines is Poor Five Years after Institute of Medicine Standards: Review of Guideline Methodologies’, Research Involvement and Engagement Journal, volume 3(19).
    • Australian Commission on Safety and Quality in Health Care 2017, National Safety and Quality Health Service Standards, 2nd ed. ACSQHC, Sydney (NSW), viewed 16 October 2019, https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf
    • Business Dictionary 2019, Policies and Procedures, Business Dictionary, viewed 21 October 2019, http://www.businessdictionary.com/definition/policies-and-procedures.html
    • Gasior, M 2017, ‘Writing Policies and Procedures in Healthcare’, Power DMS, viewed 21 October 2019, https://www.powerdms.com/blog/writing-policies-procedures-healthcare/
    • Kenyon, M 2018, ‘What are Policies and Procedures?’, Power DMS, viewed 21 October 2019, https://www.powerdms.com/blog/what-are-policies-and-procedures/
    • Leahy, T n.d., ‘The Importance Of Healthcare Policy And Procedures’, Policy Medical, viewed 21 October 2019, https://www.policymedical.com/importance-healthcare-policy-and-procedures/
    • National Health and Medical Research Council NHMRC, Plan, NHMRC, viewed 21 October 2019, https://www.nhmrc.gov.au/guidelinesforguidelines/plan
    Author Ausmed Editorial Team

    Ausmed’s Editorial team is committed to providing high-quality and thoroughly researched content to our readers, free of any commercial bias or conflict of interest. All articles are developed in consultation with healthcare professionals and peer reviewed where necessary, undergoing a yearly review to ensure all healthcare information is kept up to date. See Educator Profile



    Online Learning
    Policies and Procedures in Healthcare
    Speciality Classification
    Provider Type
    4 m
    Start Date
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    4 m
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    $30 p/m
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