NSQHS - Standard 1: Clinical Governance Standard
Policies and Procedure Action 1.7 states
The health service organisation uses a risk management approach to:
- Set out, review, and maintain the currency and effectiveness of policies, procedures and protocols.
- Monitor and take action to improve adherence to policies, procedures and protocols.
- Review compliance with legislation, regulation and jurisdictional requirements.
What is the difference between Policy & Procedure?
Policies are rules, guidelines and principles that communicate an organisation’s culture, values and philosophies.
Procedures are developed for internal use by health care providers to create a roadmap showing how a policy can be implemented or how a service can be delivered. Procedures refer to the various types of tasks performed by employees, resources that are necessary, boundaries of the service, and contingency plans for executing an alternative if the policy cannot be implemented (O'Donnell, 2012, Pharmacy & Therapeutics).
Before You Start
- Clearly define the problem the document will discuss.
- Research your policy – get input from all roles and departments affected by the policy.
- Read current literature on the topic. Literature support is available from the Library email@example.com
Keep it Simple
Your policy needs to be read and easily understood by a wide variety of people:
- Write your policy in plain English; be clear and concise, avoid complex language and long paragraphs.
- Avoid jargon, unnecessarily technical terms, or overly formal words and phrases. Use common terms. Such as ‘use’ rather than ‘utilise.’
- If abbreviations are used, first define them, abbreviations can have different meanings to different specialities across the health service.
Keep it Active
Succinct documents written in an active voice are generally easier to comprehend.
- Say it in as few words as possible. Use ‘before’ rather than ‘prior to’ and ‘often’ rather than ‘in most cases.’
- Use active voice rather than a passive voice, and write in the present tense.
- Avoid the use of ambiguous terms such as ‘should’ and ‘shall.’ For mandatory actions, use ‘must.’
Keep it Consistent
- Use the approved South West Healthcare policy and procedure template. Documents written and presented in a consistent manner aids readability.
- Define the meaning of the important terms used in the policy in the Definitions section.
- If you have a list of bullet points punctuate these consistently. This is what I recommend:
- Use a full stop after every bullet point that is a sentence (as these bullets do).
- Use a full stop after every bullet point that completes the introductory stem.
- Use no punctuation after bullets that are not sentences and do not complete the stem.
- Use all sentences or all fragments, not a mixture.
- Many words have variable spelling, policies should be written in Australian (or British) English.
- There are many different referencing styles (APA, Harvard, Oxford, Vancouver…) for consistency South West Healthcare will use the American Psychological Association (APA) style manual. For referencing support the Library can be contacted. Quick online guide Re:cite.
Keep it Current
Future-proof your policy by avoiding details that may quickly become outdated.
- Don’t use specific staff names or contact details – where possible use a generic group email address or phone number (such as firstname.lastname@example.org)
- Be conscious of linking to further information. Policies may be printed, so must make sense when read off-line in hard copy.
- Check with the Library to see what current editions of resources are available and if linking to an eBook/chapter/ journal article/ guideline is possible.
- Use the principles for the inclusion of resources if you are not sure whether to include a resource in the policy.
- If updating existing policies, check links still work and provide current information.
When You Are Done
Ask for a peer review (from the Library, someone in your team, or someone outside of your speciality that may not know the content you are explaining). The reviewer can use the above dot points as a proofing checklist.
American Psychological Association. (2010). Publications manual of the American Psychological Association (6th ed.). Washington, DC: American Psychological Association.
Australian Commission on Safety and Quality in Health Care. (2017). The National Safety and Quality Health Service (NSQHS) Standards (2nd ed.). Standard 1, Action 1.7 Polices and procedures.
National Health and Medical Research Council (NHMRC). (1999). Guide to the development, evaluation and implementation of clinical practice guidelines. Australia: Commonwealth of Australia.
Punctuating Bullet Points. (2012). Retrieved from https://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html
Snooks, L. (2005). Style manual for authors, editors and printers (6th ed.). Australia: Commonwealth of Australia.
Writing Policy Documents. (2015). Retrieved from https://documents.uow.edu.au/about/policy/write/index.html