Policies and Procedures – How to keep them relevant

Many organisations have a set of policies and procedures that help them in meeting quality and compliance standards. For some organisations, they are only a focus of attention at review or audit time and ‘fall off the radar' outside of this targeted focus on quality review and compliance. However, policies and procedures are a valuable tool in operating an effective business and supporting management and staff in their day to day role.

Policies and procedures should always be viewed as living documents. While you may have utilised a set of standard templates (such as the ones in our Resource Hub) to assist in the initial set up of your policies and procedures, tailored to your individual workplace of course, this should not be the end of development and/or review of this valuable set of documents.

We recommend that organisations take a good look at their policy suite at least every twelve months. This way you are ensuring that the suite you have is sufficient and reflects current industry requirements. In the Australian aged care sector, we have seen and will continue to see regular changes that need to be incorporated into our policies. Plus, we need to ensure that our staff are aware of these changes.

One of the biggest changes recently has been the introduction of the new Aged Care Quality Standards, which officially came into force this week from July 1st.

There are a number of key changes and expectations as a result of the new Standards, and your organisation will need to look at how it demonstrates meeting these expectations, if it hasn’t already done so. Some key topics we have recently been asked to review and update, as well as mapping to the new standards, include:

• Choice and Dignity of risk (standards 1 and 2)
• Diversity and Cultural Safety (standards 1 and 7)
• Infection control and Antimicrobial Stewardship (standards 2, 3, 4, 5, 6, 7, 8)
• Challenging Behaviours (and restraint) (standards 1,2, 3, 4, 5, 6,7, 8)
• Emotional, Spiritual and Psychological Well Being (standards 1,2,4,8)

And there are many more examples, but this gives you an idea.

So how can you keep your policy suite up to date?

Yes, I understand that going through every one of your policies is daunting, but there are a number of ways you can keep your policy suite up-to-date and relevant for your organisation and reflective of the industry.

1. Review the Commonwealth Government’s regular alerts via their newsletters and other industry advice. Make a note of anything that is relevant to your organisation and add a note to your Quality Improvement register where relevant. This will help you keep track of changes you need to make and provide you with a reminder to ensure any relevant policies and procedures are reviewed and updated.

2. Make reviewing your policies part of a regular service audit process. You probably have a set of internal audit tools that assist you to monitor the compliance and effectiveness of your organisation over the year. If you review one policy each week you’ll have reviewed 52 policies by the end of the year.
If you don’t have a policy audit log, you can download and use the version in the Total Quality Package resource hub if you have a membership. You can also get a free version from our Free Resource Pack.

3. Review your complaints and feedback register, survey results, staff satisfaction surveys, exit interviews and incident reports. Do any of these indicate a need to change or modify a policy or practice?

4. Note any comments that staff raise in staff meetings that relate to a relevant policy. Perhaps you have changed a practice and when reviewing the policy with staff, someone pointed this out. This is great, make a note against the policy, change as needed and redistribute the updated policy.

5. If you have a larger service you might like to establish a policy committee. The role of the committee members would be to regularly review the policies against any industry changes that have been logged and provide recommendations for any changes to the documents.

And of course, when you have made your changes, make sure you update your version numbers or the date on your policy and have them ratified by the relevant authority within your organisation. It’s also useful to log this in your Quality Improvement register if you are not using a Policy Audit log.

Note: If you are already a member of the CDCS Total Quality Package you will be receiving regular monthly updates on any changes made to the base template Policy & Procedure suite that you can review, and if relevant, transfer across to your own set of policies.