Why documentation is so important: Tips that could keep you out of trouble later. Who should write policies (qualifications of good policy writers). What are the differences between policies and procedures. When to use handbooks, manuals, flowcharts vs. policies. How to achieve consistency using standardized policy attributes and format. How to organize policies (classifying and numbering). When policies should be reviewed and/or revised. Our speaker Candace J. Chitty, BSN, MBA, CPHQ, PCMH-CCE is a NCQA PCMH reviewer and an expert in the NCQA patient centered medical home model and recognition process

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Candace J. Chitty
RN, MBA, CPHQ, PCMH-CCE

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 Why documentation is so important: Tips
that could keep you out of trouble later.
 Who should write policies (qualifications
of good policy writers).
 What are the differences between policies
and procedures.
 When to use
handbooks, manuals, flowcharts vs.
policies.
 How to achieve consistency using
standardized policy attributes and format.
 How to organize policies (classifying and
numbering).
 When policies should be reviewed and/or
revised.

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 Public Companies
 Answer is easy...to satisfy various laws including
HIPAA, HRSA, IRS, and other federal, state, and local
laws, and accrediting entities (TJC, NCQA, etc)
 Private Companies
 Answer is not as easy...follow similar laws as public
companies
 Not-for-Profit Companies
 Answer is easy...to satisfy various laws including
HIPAA, HRSA, IRS, and other federal, state, and local
laws, accrediting entities (TJC, NCQA, etc), and
granting agencies.
 Additionally, the new IRS Form 990 asks whether
nonprofits have certain policies relating to governance.
You don’t want to answer “no”

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 Help make instructions and guidelines definite and help
in the interpretation of policies and procedures
 Provide quick settlement of misunderstandings
 Help reduce the range of individual decisions and
discourage management by exception
 Cover recurring situations such that managers can begin
to make decisions that will be consistent every time
 Set boundaries for jobs so that each employee knows in
advance what response he or she will get from others
when taking actions, making decisions, and giving
responses
 Provide protection in the event of an audit or lawsuit

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Dissection of Key Words
 WRITING POLICIES
 EFFECTIVE WRITING
 POLICIES and PROCEDURES

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 What “Writing” IS?
 Writing policies and procedures
is more than typing words on
a page; it involves
research, writing a
draft, reviews, approvals, publi
shing, distributing, communica
tions, training, maintenance, i
mprovements, and revisions
 Writing refers to the writer.
 A writer is someone who
understands how to gather the
information, document a
process, present the words in a
logical fashion, and publish and
train the audience to ensure
the content is understood
 Also, writing means to write
consistently using a consistent
writing format and writing
style
 What “Writing” ISN’T?
 Writing content in a vacuum
without involving the users
and customers in the writing
and reviewing processes
 Buying canned
content, attaching a logo, and
calling it your own without
sanitizing it to assure it aligns
with our
environment, culture, and
resources
 Expecting non-writers to write
high-quality policies and
procedures that people will
understand and follow (a
writer of business letters does
not make a good policies and
procedures writer)

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 Good Choices
 Someone with writing and
editing skills who has the
time and mobility to
interview users and
customers
 Someone who has worked
on process improvement
projects
 Someone with excellent
organizational skills and a
passion to write documents
that can be understood by
the targeted audience
 Analysts, Subject Matter
Experts, Leads,
Supervisors, and some
Managers
 Not So Good Choices
 Individuals who write
business letters and
correspondence but have
never (or infrequently)
written policies or
procedures
 Individuals who have the
knowledge but don’t
have the time
 Individuals that take
content from others and
format it in their own
style but don’t interview
users to ensure the
content is correct

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 Identify policy/procedure topics
 Conduct research
 Write the first draft and making sure it is
reviewed and revised
 Obtain approvals, publish, and distribute
documents
 Issue communications and conduct training
 Analyze documents for improvements and
make revisions
 And the cycle continues...from writing to
revising to writing to revising...

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 Effective Writing?
 End result: Users can
understand and apply the
policy/procedure content to
their work processes
 Users have clear job
responsibilities and know
what’s expected of
them, without guessing
 Users can make better
decisions when they know
that the policy/procedure
content will not change from
one day to the next
 Policies and procedures are
consistent, accurate, and
reliable from one document
to the next
 Not Effective?
 Users ignore policies and
procedures for a variety of
reasons including:
 Author is not a credible source
 Poor or sloppy writing
 Grammatical and spelling
mistakes
 Complex or wordy content
 Unclear purpose or title
 Approver of policy/procedure is
not known to them or doesn’t
have the right authority
 Communications and training
efforts are lacking or weak
 Documents conflict with one
another
 Writing format is different from
one document to the next
 Policies/procedures change every
other week

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 Policies:
 Describe the “What” the
“Who” and the “Why”
 Are a predetermined course
of action established as a
guide toward accepted
business strategies and
objectives
 In a nutshell, “policies are
guidelines dictated by
executives and/or
extracted from regulations”
 NOTE: Other policy types
could include public
policies or institutional
policies (not covered here)
 Procedures:
 Describe the “How” and are
generally methods by which
policies are accomplished.
 Are a combination of one
or more business processes
 Identify the
people, places, processes, f
orms, and actions necessary
to carry out one or more
policies or to support or
influence other procedures
 NOTE: Procedures that
address a single process
such as how to complete a
form or cash a check are
often referred to as
“Desktop Instructions” or
“Work Instructions”

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 AGREE on the importance of a writing format and agree
on which writing format to use in which situation
 AGREE on the use of a single writing format for policies
and procedures or two writing formats for policy and
procedure documents; and one desktop instruction
format
 AGREE on communications media to be deployed
 AGREE on training methods to be utilized and repeated
 AGREE to write a “Procedure on Procedures” to
capture the essentials of writing policies and procedures

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1. What’s the justification?
2. Who authorizes?
3. Who manages function?
4. Who writes policies and
procedures?
5. Do you deploy printed
and/or online manuals?
6. Do you use 1 writing
format, 2 writing formats;
and desktop instruction
formats
7. What’s your document
numbering system?
8. Where does content come
from?
9. What’s the layout of your
writing format?
10. Are forms designed to align
with policy and procedure
content?
11. Who reviews drafts?
12. Who approves drafts?
13. Who distributes and
publishes documents?
14. Who communicates?
15. Who trains?
16. Who audits?
17. Who monitors to ensure
current regulations are
taken into consideration?
18. Who recommends
improvements?

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1. Management shows commitment to policies and
procedures by authorizing the policy/procedure
function
2. Person/team is assigned to write/manage policies and
procedures from research to publishing to revisions
3. Topics are identified and researched
4. Drafts are written in a standard writing format
5. Drafts are reviewed by users and management
6. Drafts are approved (finalized) and published
7. Published documents are communicated and trained
8. Published documents are revisited to study possible
improvements and cost savings
9. Published documents are subjected to a revision
process that starts at #3 and the whole “topic-to-
revision-process” becomes a continuous cycle

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 Heart of a policies and procedures system
 A writing format is a way to:
 Present your content in a logical and easy-to-read
sequence that makes sense to the targeted audience.
 Present enough information about your content that helps
the audience understand the importance of your policy or
procedure topic.
 Ensure consistency from document to document for both
the policy and procedure documents.
 A writing format contains a specific number of
section headings and never changes after the
writing format is approved for use

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 Header – Logo, title, number, dates, approvals, revisions
 1.0 Policy Statement
 2.0 Responsibility
 3.0 Definitions
 4.0 Implementation (Procedures)
 5.0 Documentation/Monitoring
 6.0 References
 7.0 Related Policies and Procedures
 Optional documentation (appendices can be used as a way
to include flow charts, diagrams, and other material)
 Adding Section Headings
 Possible additions include “Background,” “References,”
“Document Approvals,” or “Disciplinary Actions”. If you add
more headings, integrate them into the writing format and stick
with that number of section headings
 Never deviate for any reason: Consistency is King

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 Selections:
 One (1) Writing Format that combines
policy and procedure elements
 Two (2) Distinct Writing Formats:
 One (1) for a Policy Document
 One (1) for a Procedure Document to cover
two or more business processes

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 Combines policy and procedure elements
into a single writing format
 WHY? Reduces redundancies, duplication, and
inconsistencies when two documents cover the
same, or similar, subject
 Eases reading by the targeted audience by:
 Providing a logical sequence of section headings starting
with “Purpose”...and ending with “Revision History”
 Not asking the reader to search out two documents that
cover the same, or similar, subject(s)
 Eliminating redundancy of two documents published on
similar subjects

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 Writing Format for single processes such as:
 How to fill out a “Travel Request” form
 How to request “Petty Cash”
 WRITING FORMAT Section Headings
1.0 Purpose
2.0 Procedures (Step-by-Step Actions)
3.0 Change History
4.0 Document Approvals

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 Logo
 Title
 P/P Number
 Department/Operational Area
 Effective Date
 Review, Revision, and Approval Date
 Approvals
 Page Numbers
 Scope

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 Describes
objectives, strategies, goals, culture, vision, mission
, and other guiding principles for the topic stated in
“TITLE” and “PURPOSE”
 Can be a single paragraph, several sentences, and
sometimes several pages
 Opening sentence might say: “The policy of XYZ
company is to: (Follow with statements or indented
sentences)”
 Be careful:
 Don’t omit the “Policy” section heading when you don’t think
there are any policy statements surrounding procedures
(there is always a policy that guides a procedure, always)
 Writing policy statements that don’t support the main focus
of the “Purpose” section heading or the “Title” of the
document
 Using specific procedural statements instead of general
policy statements

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 Summary of roles and responsibilities of the individuals or
groups that perform actions in a policy or procedure
 The “Responsibilities” section often parallels the flow of the
“Procedures” section, where applicable
 The responsibility section typically has at least two
sentences:
 “The [Title of Highest Approver] shall ensure compliance to this
policy (or procedure)”
 “Employees are required to…”
 Be Careful:
 There must be a “compliance” statement in every policy or
procedure document
 Don’t write procedural statements in this section; rather keep to
the responsibilities of the roles stated
 Don’t write actual names of persons; instead state only their roles
or functions

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 Defines objects or terms like
acronyms, abbreviations, forms, reports, flow
charts, models, words infrequently used, or technical
jargon
 Don’t assume your audience has the same vocabulary as
you
 Be Careful:
 Never omit a section heading
 Not to leave this section blank: All policies and procedures
have definitions of some sort
 Failing to define content in this section that is later placed
in the appendices as an exhibit or reference pointer

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 The Implementation section heading describes the
rules, regulations, activities, timing, place, and personnel
necessary to carry out the intent of the procedure and/or
support the essence of the policy statements contained within
the Policy section heading
 The Implementation section heading is required for procedure
documents but is optional for policy documents
 Be Careful:
 Never omit this section even if there is no content for a
policy document
 Ensure that the procedural statements support the policy
statements
 Ensure that the procedural statements follow the work flow

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 Contains information related to documentation
requirements
 Describes any surveillance and or monitoring activities
to ensure/track compliance
 Be careful:
 Assure that all monitoring requirements are included in
quality assurance/quality improvement planning
 Don’t omit this section. If there are no documentation or
monitoring requirements indicate by entering “

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 Contains information related to references used in
writing the policy content.
 Example:

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 Crosswalks all related policies, procedures, and perhaps
additional documents
 Assists in managing consistency across documents when
needed revisions are needed. Writers should conduct a
consistency review of all related documents listed in this
section when revising to ensure consistency remains
throughout.
 Example:

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 Optional documentation can be added to any policy or
procedure document
 One method is to define the documentation (like a flow chart
or report) in the “Definitions” section and refer to an
appendix where the document has been included
 Another method is to hyperlink a reference for electronic
policies and procedures (opens in its own window)
 In the case of a form, define it in the “Definitions”
section, and either add a hyperlink to the template or in the
case of paper forms, give directions on where to find the
form (like a supply cabinet) and show a sample image in an
appendix
 Be Careful:
 Don’t include an appendix without a reference notation from
somewhere in the document or from the “Definitions”
section
 Don’t include a reference in the “Definitions” section and
then fail to include the actual reference document or source
either as a hyperlink or as an appendix to the document

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Two Methods:
1. Quickest... but acceptance is difficult: Find or
purchase a canned (generic content) policy or
procedure you like from a website or book, don’t
change a word, add your logo, and call it your own.
Unless you adapt content to your culture and
people, buy-in is highly unlikely
2. Best Method: Assign at least one writer and/or form a
cross-functional team, do research, use canned content
for reference purposes only, interview
users, brainstorm ideas, write a draft document, get it
reviewed and approved, publish it, and communicate
and train

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Now that the policy/procedure document has
been
written, reviewed, approved, published, and
distributed,
the NEXT STEPS are to:
 Communicate and train
 Work on improvements for the next
revision
 Update the document publish the revision
 Communicate and train...and so on

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 Communications are key to policy/procedure implementation
because it’s a quick way to impart information about
policy/procedure content
 Communication Methods can include:
 Distribution of physical or electronic documents
 Letters, press releases, newsletters
 Paycheck stub or inserts
 Posters, bulletin boards, or brochures
 Team meetings, town meetings, staff meetings
 Email messages or broadcast emails
 Intranet news items
 The KEY is to provide communications in multiple ways to give
the reader added ways to understand the material. Keep in
mind that the “just once” communications method and plan is
not acceptable and plans must be made to communicate
regularly to ensure continued understanding on the behalf of
the employee and to reduce the tendency to “resist change”

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 Training is defined as to make prepared, to teach to be
proficient, to undergo instruction, or to practice.
 In business, training is the formal process used to
develop in an employee the attitudes, knowledge, and
skills an employee needs to make him or her capable of
efficient performance (i.e., less time to carry out
assignments).
 Training methods include but are not limited to:
 Lectures, workshops, or seminars
 Department or staff meetings
 On-the-Job Training
 Multimedia training and/or computer-based-training
 Mentoring and coaching
 Other creative training methods
 The KEY is to train and then to repeat training through
on-the-job training and mentoring.

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We have learned:
 Writing Effective Policies and Procedures is NOT as
simple as borrowing content, adding a logo, and calling
it your own
 Policies and procedures writers don’t just write and
edit but they are also responsible for
researching, writing, reviewing, approving, publishing,
communicating, training, improving, and revising.
 Incorporating a consistent writing format will:
 Help the reader understand content quicker
 Ensure consistent and accurate policies and
procedures from one document to the next.
 Most importantly, we have learned that a writer’s job
is not over when the document is published...INSTEAD
the writer’s job is just beginning…with
communications, training, reviews, audits, improveme
nt activities, and revisions.

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 Management commitment to write policies and
procedures
 Qualified writers---More than just an editor
 Same writing format template used every time
 Communications issued in multiple media
 Training offered in a variety of formats
 Walk the Talk from management
 Mentoring and On-The-Job Training
 Ensuring legal review of all relevant policies
 Annual policy/procedure reviews
 Adding policy and procedure understanding as
a percentage on an employee’s evaluation plan

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1. Select a writing format and stick with it
2. Write a “Procedure on Procedures” and stick with your
decisions as you write policies and procedures
3. Designate a policies and procedures writer and give this
person the tools, time, and mobility he/she needs to be
successful
4. Don’t expect to be able to take a canned financial policy
or procedure, make a few changes, add a logo, and call it
your own if you actually want people to read and apply the
content
5. Put a policies and procedures writer in charge, follow my
advice, and do it right the first time...so that readers might
actually read the documents and apply the guidelines to
their jobs
6. Be proactive, as you are doing today, by listening to me
talk, and by attending conferences, and learning tested
methods for writing effective policies and procedures

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Questions & Answers
Thank you for participating in the continuing
PolicyPLUS Webinar series. If you have any
comments or additional questions please
do not hesitate to contact us.
CJChitty@Qfhc.com RChitty@Qfhc.com
www.Qfhc.com www.Qfms.org