1. Tips for Policies and
Procedures
Lydia Lehnertz, WI AHEC CHIP Intern - Buffalo County
& Alyssa Weinrich, WI AHEC CHIP Intern – Pepin
County
2. Introduction
• Assigned to project from Wisconsin Area Health
Education Center (AHEC) Community Health
Internship Program (CHIP) within Pepin and Buffalo
Counties.
• Goal to update policy and procedure manual to a
standardized electronic format
• Created PowerPoint to help others find an effective
way to update, maintain and create policies and
procedures in an electronic format
4. Standardized Table of Contents
Useful components of electronic table of contents:
1) Subheadings organized in logical way
2) Columns for dates effective, reviewed, and revised
3) Policies hyperlinked from title listed in table of
contents
5. Example Table of Contents
Pepin County Public Health Department Policy & Procedure Manual
Policy & Procedure
1. Administration
Effective Revised
A.
B.
C.
D.
Administrative Policy
Background Checks for Employees
Accident/Injury (employee or client)
Job Descriptions
01/05/10
12/03/03
10/01/03
07/01/03
06/15/12
Blood Pressure Screening of Adults
Wisconsin Well Women Program
11/10/03
05/31/07
06/26/12
06/20/12
Communicable Disease Investigation and Control
Infection Control/Bloodborne Pathogen Exposure Control Plan
12/19/07
07/16/09
Response to Public Health Emergencies
05/31/08
07/03/12
Home Visitation: Elimination of Second Hand Smoke Exposure
Recreational Water: Restricted Use/Closure
09/05/08
08/01/03
Reviewed
06/28/12
6/29/2012
7/1/2012
06/28/12
2. Adult Health
A.
B.
3. Communicable Disease
A.
B.
4. Emergency Preparedness
A.
5. Environmental Health
A.
B.
06/25/12
6/22/12
07/01/12
6. Guide to Hyperlinking
2 different options:
1)
You can hyperlink existing text
Ex: A hyperlink for policy xyz…
2) You can select location where you want hyperlink
after text
Ex: A hyperlink for policy xyz can be found here:
s://publichealth/policy/xyz
7. How to Hyperlink Existing Text
•
•
•
•
•
•
Highlight words you want to hyperlink
Right click your mouse
From dropdown select hyperlink
On left hand side select “existing file or webpage”
Select location of file
Click “ok”
8. How to Hyperlink Following Text
•
•
•
•
•
•
Place curser where you want to hyperlink
Right click your mouse
From dropdown select hyperlink
On left hand side select “existing file or webpage”
Select location of file
Click “ok”
9. How to Open a Hyperlink
• Right click the text you hyperlinked
• Select “open hyperlink” from dropdown menu
• File should open automatically in new window
10. Standardized Template for
Policies and Procedures
• Found many different methods for structuring policy
and procedure manual
• Decided to use format that included purpose
statement, policy, procedure, references/legal
authority
• Could possibly add other components such as:
responsible staff, definitions, supplies needed,
related policies
• Key to keep the policy and procedure as SIMPLE as
possible
11. Example Policy Template
POLICY TITLE:
EFFECTIVE DATE:
DATE REVIEWED/REVISED:
AUTHORIZED BY:
PURPOSE STATEMENT:
POLICY:
PROCEDURE:
REFERENCES/LEGAL AUTHORITY:
12. Policy Review
• There is no set guideline as to how often policies
need to be reviewed; however, they need to be kept
current
• Local policies at each health department give the
specific details within their policies (ex: create and/or
execute a policy on policy revisions)
13. Tips for Keeping Policies Current
• Use a table of contents with columns for effective
date, date reviewed/revised
• Develop a sign-off sheet to be kept in a central
location
• Create a revision log which allows you to make note
of future changes needed to policies
• Find an effective method for keeping revisions
current (ex: policy review at staff meetings, individual
accountability)
15. Archiving Documents
• Health Departments should have their own policy on
policy retention
• One option for organizing policies is to create
“archived policies” folder within electronic policy and
procedure manual
• Organize based off method that works best for your
health department
16. Tips for Accreditation
• Policies and procedures cannot be drafts
• Must be in electronic format
• Must have documentation for each standard and
measure within
Public Health Accreditation Board Standards and Measu
17. Helpful Resources for Accreditation
• National Association of City and County Health Officials
(NACCHO)
- Contains toolbox with examples of each domain
• Public Health Accreditation Board (PHAB)
- Contains structure and guidelines for accreditation
process
• Public Health Accreditation Wisconsin (PHAW)
- Private webpage available upon request from
regional office
18. PHAB Website
• Found to be very helpful throughout this process
• Contains standards and measures necessary for
becoming accreditation
• Each measure requires documentation to prove
compliance
• Next slide outlines measures that may require a
policy and procedure
19. Policies and Procedures Necessary
for Accreditation in 2012
Measure
Description
2.2.1A
Two examples of written protocols for containment/mitigation of health problems
and hazard
2.3.1A
Outline how the health dept. maintains 24/7 access to support services in
emergencies. May be in the All Hazards Emergency Operations Plan or separate.
2.3.2A
Policies and procedure that assure 24/7 laboratory coverage may be in the all
Hazards Emergency Operations Plan or separate protocols for the handling and
the submission of specimens.
2.3.3A
Identify support personnel who will be called on to provide surge capacity
5.4.2A
Written communication protocols that provides a means for the department to
contact health care providers, response partners, the media, and others 24/7. Must
include contact information and be updated at least annually.
6.3.1A
Written procedures for communications, updated biennially that include: 1)
Disseminating accurate, timely, and appropriate information for different audiences
2) informing and/or coordinating with community partners for the communication of
targeted and unified public health messages 3) Maintaining a current contact list of
media and key stakeholders 4) Designating a staff position as the public
information officer 5) Describing responsibilities and expectations for positions
interacting with news media and the public
6.3.2A
Protocol for scheduling inspections of regulated entities
20. Policies and Procedures for
Accreditation Continued
Measure
Description
6.3.5A
Must provide a communication protocol for interagency notifications. The health
department must provide a protocol for notifying the public when required.
9.1.1A
Document leadership’s engagement in setting a policy for and/or establishing a
performance management system for department
10.2.1A
Human subjects research protection policy. If never involved with research that
involves human subjects, a policy stating that fact
11.1.1A
Must provide written operational policies in hard copy or electronic format.
Reports of review at least every 5 years or proof of regular updating process.
Description of methods for staff access to policies.
11.1.2A
Maintain written policies regarding confidentiality, including applicable HIPPA
requirements.
11.1.3A
Policy and procedure for the development of interventions and materials that
are culturally and linguistically appropriate for the population it serves in its
jurisdiction.
11.1.4A
Human resource policy and procedure manual or individual policies. The
policies and procedures must address the following: Personnel recruitment,
selection, and appointment; equal opportunity employment; salary structure;
hours of work; benefits package; performance evaluation process and
individualized development plans; problem solving and complaint handling,
including sexual harassment. Written description of how staff access human
resources policies and procedures.
21. Conclusion
• Keeping policies current is easier said than done
• Find a method that works best for your health
department
• Best of luck and remember to keep it simple!
