In the consultancy work we do, one of the biggest challenges that organisations often seek some guidance around is the development, or review, of their policies and procedures and other related documents. Managers want to make sure that they have a structure in place that provides guidance to their team, or to their successor, on what needs to be done, how it’s to be done, by whom and why it’s done.

But where to start?

Step One is to do an audit of what’s current, what’s no longer relevant or redundant.

Colourful paper in a tipped over wire rubbish bin.

You might feel a little like Wall-E, that cute little rubbish sifter robot from Disney’s Pixar Studios, wading your way through the piles of information, old and outdated legislation, redundant guidelines, irrelevant processes. But don’t lose sight of that ultimate goal; a cute little friend in Wall-E’s case, part of a clear and relevant governance structure in yours!

If your organisation has a mix of information and policies and procedures and you identify areas of duplication, it may be helpful to assess the ‘groupings’ and what really fits where. By this I mean overall categories, for example you might group your policies, procedures and related documents in the following way:

  • Governance and Management
  • Clients services / Direct Care
  • Work Health & Safety
  • Infrastructure
  • Human Resources
  • Medications

Step Two is to get clarity:

Clarity about what is, or should be, a policy, what your procedures actually are, and what really should be a work instruction, sometimes also referred to as ‘SOPs’ (standard operating procedures), or perhaps a checklist.

Businessman reading documents with magnifying glass

An easy way to identify the difference is thinking of the following:

A policy is something that defines the organisation’s position, rules or guiding principle on a particular issue or key deliverable area. They are the ‘what and why’ you take a particular stance.

Procedures are the steps that need to be followed to achieve the policy or key outcomes and are focused on the how, who and sometimes the ‘when’.

Work Instructions or SOPs are usually very task focussed and based on one key process, such as how to submit a Medicare claim, set up a Centrepay deduction, or Admit a Resident. Work Instructions are good for defining the step-by-step actions around a task that needs to be completed the same way each time. They are good for ensuring the job gets done right and also good where there are long gaps between doing something, like logging in to do a monthly claim or where there may be a high turnover of staff.

Step three is to work on the structure of your documents.

Sometimes the documentation we’ve come across can look like Wall-e’s backyard: a bit of mess. This happens when people cherry pick from different sources but then don’t format the information into a consistent format. There’s no problem taking the lolly shop approach and picking out the best information and documents for your service, but make them yours and organise them. After all you want them to be easy to read and follow a consistent approach. Having a clear structure to your documents will help your team to know where to find specific references.

Step four is to identify who is responsible for approving and maintaining each of the identified documents.

Some policies should be signed off by your executive governing body and some are okay to be approved at management level.

In some organisations, only high level ‘policies’ may need to be approved by the Board or Council, for example these may be policies relating to:

  • Approved Provider
  • Financial Management
  • Regulatory Compliance
  • Risk Management
  • Service Delivery Standards

All other policies and procedures would then be approved at the Senior Management level, like the CEO, the EO/DON, Regional Manager; it all depends on the governing structure your organisation has in place.

Step five is to arrange or store your information in a way that is easy for everyone to access and find what they are looking for.

This is where having a good information management system comes into play. This can be something simple, such as clearly labelled folders on your computer and good, solid version control (make sure that version control register is maintained), or an electronic information management system that manages the version control for you. Whatever you use, make it work for you. Any system is only as good as the person inputting and maintaining it.

For those of you who are looking for some clear, concise, relevant and up-to-date policies and procedures that are in a consistent format and structure, then why not check out the CDCS Total Quality Package resource hub.

In our next blog, we will look at another key resource that a lot of Managers literally swear by, some even referring to them as ‘Survival Guides’… these are ‘Operations Guides’ and there are a few variations on those too!

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Donna Cross & Carrie Akhurst
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