‘Policies and procedures’ is the first component of Patient Safety and Quality Systems, as outlined by the National Safety and Quality Health Service Standards: Standard 1 Clinical Governance.

Patient Safety and Quality Systems

Purpose: Patient safety and quality systems are in place within governance processes to allow organisations to advance the safety and the quality of patients’ care (ACSQHC 2022).

Policy v Procedure: What’s the Difference?

Policies and procedures are the first things an organisation should establish in order to operate effectively.

Policies

Policies are rules, guidelines and principles that communicate an organisation’s culture, values and philosophies (PowerDMS 2020a; Business Dictionary, as cited in Clark 2016).

Policies include:

• Employee entitlement and what they can expect from the organisation
• What the organisation expects from their employees
• What consumers and the community can expect from the organisation.

(PowerDMS 2020a)

Procedures

Procedures provide step-by-step instructions for routine tasks. They should also allocate people to be responsible for certain tasks. Procedures should make it clear which steps should be taken in common scenarios and who should be reported to. A checklist may be involved (PowerDMS 2020a).

Procedures may include:

• Handling complaints
• Documentation and handling healthcare records
• Managing patient aggression.

Policies and procedures are fundamental for consistency across an organisation, for both staff and consumers. They guide the organisation, influencing and determining all major decisions and actions, and reduce liability risks (PowerDMS 2020a).

Policies and procedures should be widely accessible and cover all activities carried out by the organisation. All policies should be laid out in the same format and should be written in common language that all staff members can comprehend (PowerDMS 2020b).

The Quality Systems planning process may involve steps such as:

• Establishing a policy team or group
• Identifying possible conflicts of interest
• Engaging with stakeholders
• Engaging with consumers
• Engaging Aboriginal and Torres Strait Islander Peoples and diverse groups
• Analysing purpose and context
• Defining the scope of the policy or procedure
• Altering, adapting or starting from scratch
• Investigating:
  • Transparency
  • Implementability
  • Equity.

(NHMRC 2019)

The implementation of a new policy should be followed by this process, at a minimum:

1. Distributing policies and having all employees sign them
2. Ensuring that staff are all trained on the new policy
3. The compliance and effectiveness of policies should be monitored
4. A policy review cycle should be established.

(PowerDMS 2020b; NHMRC 2019)

Policies and Procedures in Healthcare

Policies and procedures are an incredibly important part of making sure staff know how to care for patients and how to carry out tasks with confidence. Policies and procedures provide standardisation in everyday operational activities, which helps to foster consistency in practices, decrease mistakes, and keep both patients and staff safe (PowerDMS 2020b; RLDatix Marketing 2020).

The NSQHS Standards outline that a health service should manage risk in the following ways:

1. By reviewing the effectiveness of policies, procedures and protocols
2. By taking action to improve adherence to these systems
3. By reviewing compliance with legislation, regulation and jurisdictional compliance.

(ACSQHC 2021)

Policies and procedures are particularly crucial in healthcare as it is an industry that is very familiar with crisis; healthcare organisations endure a high rate of liability risks. When appropriate policies and procedures are in place, an incident is easier to navigate (PowerDMS 2020a).

This is because procedures outline the actions that an employee and manager should take when an incident occurs. Additionally, reviewing policies, procedures and incident reports may help those in leadership positions to identify what went wrong and prevent incidents from reoccurring (Kenyon 2018).

Policy and Procedure Review

It cannot be overstated that policies and procedures must be constantly reviewed and updated. Healthcare standards and regulations are constantly fluctuating. At a minimum, these documents should be refreshed annually and each time a new law or regulation is put in place or updated (PowerDMS 2020b; RLDatix Marketing 2020).

Patient Involvement

In recent years, the notion of patient involvement in reviewing policies and procedures has gained traction. Both clinical and non-clinical committees should regularly review all policies and procedures (Armstrong & Bloom 2017).

Patient involvement is a relatively new concept and is yet to be embraced completely. This could be viewed as an opportunity wasted. Patient and public contributions to policy and procedure development can include:

• Evaluation of guideline priorities
• A re-focus towards holistic approaches to care
• Broaching new topics
• Identification of populations and outcomes
• Suggestions as to whether findings are meaningful or relevant
• Determining how or to what extent recommendations interact with patient values
• Prompting the use of common-language within these documents.

(Armstrong & Bloom 2017)

Conclusion

Together, policies and procedures help to ensure that the ethos and vision of a health service organisation are communicated into tangible steps that lead to the outcome of safe, high-quality healthcare.