Updated May 2023

One of the biggest challenges we see as consultants is the lack of currency in organisational policies, procedures, and other related documents. Managers want to ensure that they have a structure in place that guides their team, or their successor, on how, what and why something is done, and by whom, but they have so many demands on their time that once this structure is set up, it's easy to overlook the fact that these documents are ‘live', that they need constant revision and updating, especially in light of aged care reforms and legislative changes.

So 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.

Here's where you'll want to channel your inner Wall-E, you remember him, that cute little rubbish sifter robot from Disney’s Pixar Studios. You'll probably feel a bit like him, wading your way through the piles of information, old and outdated legislation, redundant guidelines, and irrelevant processes. But don’t lose sight of that ultimate goal; a cute little friend in Wall-E’s case, developing a section of a clear and relevant governance structure in yours!

If your organisation has a mix of information across a myriad of policies and procedures, evaluating how these are grouped and organised can be helpful. This involves considering the overall categories in which your policies, procedures, and related documents fit. Here are some examples of potential groupings:

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

Step Two is to get clarity:

It's important to gain clarity on the distinctions between policies, procedures, and work instructions (also known as SOPs or checklists).

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 and provide high-level direction, setting the overall framework for operations.

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 submitting a Medicare claim, setting up a Centrepay deduction, or admitting 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 our policies, procedures and other documentation can resemble Wall-E's backyard – a bit of a mess. This often happens when people pick and choose from various sources without putting the information into a consistent format. It's like someone's gone out to a candy shop and selected the tastiest treats for your service, it's fine, but remember to make them your own and get them organised and formatted. After all, you want these documents to be user-friendly and follow a consistent approach. Giving your documents a clear structure will help your team easily locate specific references and ensure everyone is on the same page. So, let's tidy up that paperwork and create a harmonious documentation wonderland!

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 the management level. But you need to know which is which!

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.

And map your documents. We've noticed that when there is staff turnover, key documents can go missing. Well, they're often not missing, but no one seems to know where they are. Part of good succession planning is making sure that your successor can find essential information and they're not forced to reinvent the wheel. A simple way to do this that we've done for those using our Total Quality Package is a multipage Excel spreadsheet. You could do something similar, add all your policies and other documents to the spreadsheet including links to where they are located on your computer or shared drive.

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 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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