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Learning Objectives


  • Determine the purpose of policies and procedures.

  • Distinguish between policies and procedures.

  • Identify some expectations of The Joint Commission for policies and procedures.

  • Identify managerial actions that increase the value of policies and procedures.

  • Compare policies and procedures with other documents used by healthcare organizations.

  • Critique given policies.

  • Prepare a policy and procedure using a given guideline.

  • Discuss the responsibilities of managers for policies and procedures.


In large healthcare organizations, the development, review, and implementation of policies and procedures are driven by The Joint Commission (formerly The Joint Commission on Accreditation of Healthcare Organizations) and other accreditation and licensure requirements. One intent of these requirements is to ensure that policies and procedures are multidisciplinary in order to reduce confusion and inconsistencies about patient care that may occur among various units and disciplines.1

Because of this requirement, and the complexity of large healthcare organizations, responsibility for policies and procedures often falls to a systemwide standing committee devoted to the ongoing development and review of its policies and procedures manual.

Usefulness of Policies and Procedures

Although it will be less complex, a policies and procedures manual is important to even the simplest organization—an independent physical therapy practitioner. Regardless of size, there are several good reasons to develop and implement policies and procedures:

  • To avoid the potential trap of relying on memory to assure consistency in conducting business over a period of time.

  • To demonstrate thoughtful, thorough attention to business details for all stakeholders.

  • To serve as evidence during legal proceedings. NOTE: Wording that suggests absolutes such as always should be avoided; use typically or usually instead.

  • To meet the requirements of licensing or other agencies that may demand them.

  • To reflect the compliance of an organization's commitment to state and federal laws.

Policies and procedures cover the gamut of operations and reflect an organization's vision and mission. A sampling of the range of topics that might be found in the table of contents of any healthcare organization's policies and procedures include:

  • Charges for Patient Cancellations and No-Shows

  • Recognition and Reporting of Abuse

  • Use of Patient Restraints

  • Interpreter and Translation Services

  • Medical Device Safety

  • Patient and Family Education

  • Universal Precautions

  • Verbal and Telephone Orders

Basic Principles of Policies and Procedures

A policies and procedures manual has value only if it is used. Access to the manual is the first important criterion. A cumbersome manual that serves only as a space-taker on a manager's bookshelf will be of no value if it is opened only when a compulsory review of it must be done. An online version of a manual in which employees may search for terms increases its usability and implementation. It also reinforces the use of standardized formats as they are developed. ...

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