Saturday, January 30, 2016

How to write gourmet policy and procedure

Hi fellow informatics junkies, workflow managers, and other clinical Jedi,

I love watching the Food Network channel. Not only because it lets you watch world-class chefs prepare unbelievable dishes, but because of the business and operational lessons they sometimes impart. Two of my personal favorites are Gordon Ramsay and Buddy Velastro, who not only bring a real love for food, but also demonstrate really smart business and operational sensibilities. I have always believed that healthcare could learn some lessons from the food industry.

With that in mind, today I'd like to address the subject of policy writing. To me, policy is like food -  If you don't like it, and it doesn't nourish you, why bother with it? It's not just enough to taste good - Good policy should also be good for you

Also, like food - Good policy creates harmony and brings people together. Holiday dinners are no fun to make if you are the only person making them. They become much more meaningful when you share the labor with your family, and have a chance to talk and communicate while you wash the vegetables and boil the pasta. The same applies to policy writing : It's not just the end result that matters - It's also the road you travel to get there. 

Writing great policy and procedure doesn't have to be painful - It's actually fun once you know the recipe. It can help you create clarity, harmony, and efficiency. So with that in mind, I'd like to offer up a great recipe: How to write a gourmet policy and procedure.

Now remember, because they can become the subject of legal inquiries when they fail, policy is something you should take your time to develop. For this reason, you'll also want to consult your legal advisor before undertaking any changes to your policy process.

Also remember, procedures are workflows - So by writing good policy and procedure, you are mapping out your core operational workflows! If you have an EMR and an Informatics team, you can save lots of time by making sure your procedures are well-written, since they are key tools used to configure your electronic medical record!

Now, before we get to the recipe, just so we're all on the same page - what's a policy, and what's a procedure?

  • POLICY = Your standard
  • PROCEDURE = How you will achieve that standard
These two are often found together on the same document, because once you define something as being a standard (policy) in your organization, you will quickly need to know how you are going to meet that standard (procedure).

This is where a common question comes up - Q:"Do you NEED to have the procedure on the same document as your policy?" A : No. Some organizations choose to just define policy - And then link the policy statement to a separate procedure document, e.g. "PROCEDURE : Please see the Lippincott Manual, page ____". Either way, if you are defining a policy standard in your organization, that you can legally be responsible for upholding - you should put a lot of thought into how exactly you will uphold that standard. 

Now - Let's get to the recipe!


The first step to creating a policy is asking the question, "Do I really need a policy?" You generally don't need to create policies for things that are common sense, don't benefit your organization, or impossible to enforce. On the other hand, you *do* want policies for the important operations of your organization, especially ones that are supported by regulations.

Once you've decided that you need a policy, the next step is doing some literature search, starting with your existing policy manual - Does any existing policy already address some or all of the desired standard? You will need to do this to ensure you don't have overlapping or conflicting policies. You will also want to review other current literature, to see if there are any regulations, studies, or best-practices which support the creation of your policy.

If there is no conflicting policy, then next it's helpful to gather the organizational policy template, policy style guide, and any regulations or articles you've found which support the creation of the policy. 

Once you have clarity on your need for a policy, including the regulations and any other citations which support the creation of the policy, you will want to then take your standard policy template and policy style guide, and start to write the policy statement.

Policy statements, ideally, are short and sweet, and should clearly state what your desired standard is. An easy way to think of writing them is using this template : 

"All __________ will _________ according to the procedures outlined below."
So, as a teaching example, let's make a "Cupcake policy" that makes it mandatory for all patients to get a cupcake on arrival to an inpatient bed : 

Now that you have drafted the policy statement, you will want the reader to figure out how they can achieve this standard by writing a good procedure.

C. DRAFTING THE PROCEDURE (with time/cost/labor estimates!)

To help support our new cupcake policy, we will want to figure out exactly how the organization will support this policy. This is the place where organizations can save a lot of time and money by writing a great procedure that helps create harmony during the policy review process. Remember - procedures are workflows, and working them out regularly will help create workflow clarity, making your policies tools of budgeting, education, and harmony.

The easiest way to write a clear procedure is to use the following template : 

[ WHO ] will/may [ WHAT ] [ where ] [ how ] [ when ] [ why ] [ time ] [ labor ] [ materials

  • [ WHO ] = Role of the person who will perform this step of the procedure
  • [ WHAT ] = Task they will do at this step of the procedure
  • [ where ] = (OPTIONAL) Where they will perform this task (e.g. "in a bowl")
  • [ how ] = (OPTIONAL) How they will perform this task (e.g. "with a spoon")
  • [ when ] = (OPTIONAL) When they will perform this task (e.g. "until smooth")
  • [ why ] = (OPTIONAL) Why they perform this task (e.g. "to prepare for baking")
So for our cupcake example, we might start by DRAFTING the following procedure : 
You will notice that by writing it using this template, you have started to answer some questions : 
  • Who are the end-user stakeholders? (A: Kitchen staff, couriers, and inpatient nurses.)
  • Who will need to help review this policy? (A: Director of Kitchen Staff, Director of Couriers, and Director of Inpatient Nursing)
  • What is the cost of this procedure? (A: Time, labor, and materials of each step!)
In fact, if you wanted to get really fancy, you could potentially bring this procedure into a spreadsheet, and calculate the cost of the procedure to a penny!
I highly recommend playing around with your procedure in a spreadsheet like this - You will quickly figure out two things :
  • How much, exactly, the policy will cost you (in this case, $326.40/day in materials and labor x 365 days a year = $119,136/year!)
  • Where you might be able to save costs in this workflow (e.g. asking a courier to pass out the cupcakes, instead of inpatient nurses, could save you $80-$20=$60/hr savings x 3.33 hours = $200 savings a day x 365 = $73,000 savings/year!) 
Figuring out this cost will help prevent you from approving a policy that you don't have the resources to follow. And once you have this procedure (workflow) worked out to your satisfaction, you can then add the regulations/citations which support the creation of the policy : 
... and bring this DRAFTED policy to the stakeholders for review.

Because this procedure was written with the above template, it's pretty easy to figure out who needs to review this policy before it's brought for final approval - The people responsible for the people who will do the task, usually something like : 
  • The Director of Kitchen Staff
  • The Director of Couriers
  • The Director of Inpatient Nursing
So you will want to add their names to the "Reviewed By:" section of the policy (see below):
... and set up some time with these people to review the new policy. 


Once you meet with these stakeholders, you will want to review the policy together and ask them three questions
  1. Can your staff do the task(s) in this procedure?
  2. Do you have the budget to pay for the staff to do the task(s) in this procedure?
  3. Can you educate the staff to perform the task(s) in this procedure properly?
If the answer to any one of these questions is "NO", then it means that either the policy should be edited, rewritten, or delayed until issues can be resolved.

If the answer to all three of these questions is "YES", then ideally, you would seek their signature under the "REVIEWED BY:" section of the policy : 

In some organizations, you might need to seek additional signatures under the "Reviewed By:" section, such as a person from quality to review the policy name and coding are correct and that the spelling and citations are all correct. To see if there are additional signatures, you will want to refer to your organization's standard policy process, usually kept by your policy coordinator.


Once you have the signatures required for final approval, you will again want to refer to your organization's standard policy process, and arrange for the policy to be approved and published. 

Ideally, there is only one signature required for approval, so that the policy can be briefly reviewed in a committee, approved by vote, and then whoever is authorized to approve policy for the organization then signs it, making the policy an active policy : 
Sometimes, usually for political reasons, some organizations have decided to require two signatures for approval, to create a system of checks-and-balances. While this is sometimes helpful, it can also delay policy approval if you don't have both people in the room at the same time. (E.g. one person might agree to sign the policy after a committee vote, but then the second person later decides not to sign the policy = This ends up delaying the approval and frustrating the committee.)


After approval, the person with authority to give final approval should then follow your organization's standard policy process to make sure that the policy is correctly indexed and published in the organization's standard policy manual.

Sometimes, policies will contain an "ACTIVE DATE:" in the language, to allow for policies to be approved before they become active (e.g. approving a policy in February for a project that goes live in March). If the policy clearly states the "ACTIVE DATE :", then you can place it in (or upload it to) your policy manual before the actual active date. 

When a policy is published to your organization's manual, you will now want to send a notice to the people who will be expected to follow the policy - In this case, the kitchen staff, the couriers, and the inpatient nurses.

Finally, you will want to make sure the stakeholders actually educate their teams about the new policy, and assemble whatever resources are necessary to start the new workflow on the expected start date.


Policies should be monitored for effectiveness by the stakeholders, as soon as they are approved and published. Sometimes the question arises, "What if someone breaks a policy?". While this is a problem, it should not mean immediate punishment or remediation. Instead, it should trigger an inquiry and discussion of what-went-wrong : Was the policy incorrect? Not educated properly? Not budgeted properly? Incorrectly written?

If the inquiry reveals no problem with the policy, then usually it is just a matter of some re-education or remediation, to correct the issue. This deficiency should still be tracked and noted for future review of the policy.


Policies should be reviewed at least every 2-3 years, to ensure that they are still effective, properly educated, and properly budgeted for. Sometimes organizations make budget changes that impact policy function - Ideally, you will want to catch those workflow changes as soon as possible, but by making it a habit to revisit your policy at a minimum of every 2-3 years, it will help make sure that your policy is accurate, functioning, and up-to-date with current regulations.

Remember - Good policy reduces cost and creates operational clarity and harmony. Bad policy does the opposite. Always review your policy needs, make sure you don't already have an existing policy/conflict, and review your organization's standard policy process and template before you start writing!

Finally, a great reference (for those seeking more information on policy writing) is Writing Effective Policies and Procedures : A Step-by-Step Resource for Clear Communication by Nancy J. Campbell (1997). It's a big book, but the first few chapters are fantastic in explaining the basics, and the rest of the book is a great reference for how to tackle more complicated policy issues.

I hope this has been a basic, helpful review of policy and procedure development! Always ask your policy coordinator and legal counsel for advice before making any changes to your current template or process! Feel free to leave your thoughts and feedback in the comments below!