What are the best practices for developing policies and procedures that meet accreditation standards?

1 Assess your current situation

Before you start writing or revising your policies and procedures, you need to assess your current situation. This means identifying the accreditation standards that apply to your organization, such as those from The Joint Commission, the National Committee for Quality Assurance, or the Accreditation Association for Ambulatory Health Care. You also need to evaluate your existing policies and procedures, and check if they are aligned with the standards, updated, consistent, and accessible. You can use tools like gap analysis, audits, surveys, or feedback to find out where you need to improve.

2 Define your goals and scope

Next, you need to define your goals and scope for developing or updating your policies and procedures. What are the main objectives and outcomes you want to achieve? Who are the target audience and stakeholders for your documents? How will you measure the effectiveness and compliance of your policies and procedures? How will you communicate and implement them? You should also consider the scope of your project, such as the number, type, and priority of policies and procedures you need to work on, and the resources, budget, and timeline you have available.

3 Follow a standard format and style

One of the best practices for developing policies and procedures is to follow a standard format and style. This will help you ensure consistency, clarity, and readability across your documents. A standard format typically includes elements like title, purpose, scope, definitions, roles and responsibilities, procedures, references, and revision history. A standard style involves using clear and concise language, active voice, bullet points, headings, and numbering. You should also use a consistent naming convention, numbering system, and file format for your documents.

4 Involve the right people

Another best practice for developing policies and procedures is to involve the right people. This means engaging the staff, managers, and leaders who are responsible for or affected by the policies and procedures. You should also consult the experts, such as legal, regulatory, clinical, or technical professionals, who can provide guidance and feedback on the content and accuracy of your documents. By involving the right people, you can ensure that your policies and procedures are relevant, realistic, and reliable.

5 Review and approve your documents

Once you have drafted your policies and procedures, you need to review and approve them before you publish and distribute them. You should have a clear and documented process for reviewing and approving your documents, such as who is responsible for checking, editing, and validating them, and who has the authority to approve and sign them. You should also use tools like checklists, templates, or software to help you review and approve your documents. Reviewing and approving your documents will help you ensure that they meet the accreditation standards and the best practices in your field.

6 Monitor and update your documents

Finally, you need to monitor and update your policies and procedures regularly. You should have a system for tracking and reporting the implementation and compliance of your policies and procedures, such as audits, surveys, or indicators. You should also have a mechanism for collecting and analyzing feedback and suggestions from your staff, patients, or accrediting bodies. You should review and update your policies and procedures at least annually, or whenever there are changes in the accreditation standards, the best practices, or your organization. Monitoring and updating your documents will help you maintain and improve your quality and safety.

7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?