Writing a policy and procedure from scratch

For care providers policies and procedures are key to effective service provision. Sadly, for many years these have been left to gather dust on the shelf or the virtual shelf of the IT system. Policies define the organisations view on the subject and procedures set out how that view is to be delivered in practice. For care providers who need policies and procedures or who wish to improve the existing ones there are a number of options. These include; purchasing model policies, “borrowing” from other organisations and developing in house policies. All of these have pros and cons and I will leave that for another time. In this article I will focus on some suggestions for the last of these options, that is the development of in-house policies. 

Do your research

·        Identify relevant legislation – the CQC website gives a good starting point for which legislation applies to which regulation. Even though this refers to the English legislation it has commonality with the legislation in other parts of the UK. Make a note of the legislation and download the current version (make sure that you don’t get an out of date or draft version)

·        Identify evidence based best practice – the NICE website is a great place to start. There is NICE guidance on most social care subjects. Download the guidance and also follow links to other relevant guidance. Make a note of the titles of the guidance.

·        Look for other guidance – The CQC website has lots of good information such as the Learning from Safety Incidents series and the FAQ on Medication. Use this to add to your research portfolio.

Document what you do

·        Put your research to one side, document your existing procedures in a step by step format. This will form the basis of your new procedures. Make sure that you document what actually happens not just what you think should happen. These are often very different in reality.

Bedtime reading

·        Read the legislation and evidence based best practice. Thankfully, legislation is now written in much plainer English and does not require a doctorate in legalisticalese to understand it (OK, I made up that word!!!). Reading the legislation and best practice is best done in small doses, nobody wants and overdose of legislation do they. Make notes and identify bits that are important and relevant to your practice. Post it notes, highlighter pens and highlight text on the computer were made for this purpose. 

Don’t be a loner

·        Involve people in the process. Who? The people who will be affected by the policy and procedure, these are your team and the people you support. You could convene a focus group, team meeting or even coffee and cakes. Whatever you do, make sure you involve them rather than just dumping the work onto them and hightailing it off to somewhere more “important”.

Decide on a structure

·        Wouldn’t it be lovely if every policy and procedure followed a set format? Well, now you have the chance to do just that. Decide on a structure and stick to it. This is my suggested structure.

o  Title

o  Relevant legislation – list the laws

o  Evidence based best practice

o  Other guidance

o  Policy – this describes the organisations view on the subject. Ideally this should be short and simple rather than longwinded. The policy must be consistent with legislation and best practice.

o  Procedure – this will form the bulk of the document, this sets out exactly how you and your staff will ensure that the policy is delivered in reality. Again this must be consistent with best practice.

o  Forms – if your policy and procedure requires forms to be completed, refer to the form in this section. Warning: make sure that you cross reference forms to policies and ensure that when you update one you update the other.

o  Sign-off – the policy should be signed off by someone responsible for the service. This will usually by the Registered Manager and/or Nominated Individual.

o  Date – so we know when it was developed

Align practice to legislation

·        Ok, so this is where we get down to the nitty-gritty. Go back to the documentation of current practice. Review this in line with legislation and best practice and CHANGE AS LITTLE AS POSSIBLE!!!!! In this way people will be able to recognise most of the practice in the procedure and are therefore much more likely to follow it.

Testing 1-2-3

·        What use is a procedure that does not work in practice? Test it robustly, this is where you can use your experts (staff and people who use your service).

·        Tweak away until you get something that everybody loves.

Sharing is caring

·        After so much hard work it would be a shame to consign your policy and procedure to a life on  that dusty shelf (or the far reaches to cyberworld). So, share it with your staff team and other stakeholders.

Talk all about it

·        Discuss in:

o  Team meetings

o  Service user meetings

o  Newsletters

o  Supervisions

Tell the trainer

·        Make sure that any training is consistent with your policy and procedure. Trainers are good but they aren’t psychic!  Elearning is definitely not psychic. So, make sure that all training refers to your policy and procedure.

Antiques roadshow – OH NO!

·        Your brand new policy and procedure can easily be out of date, all it takes is a change of legislation or best practice. So, keep your research up to date and review when needed.

·        Guard against the annual review which as we all know may just consist of changing the date at the bottom of the policy.

Put it into practice

·        There is no greater criticism of your practice than “the service was not following it’s own policy and procedures”. Make sure your audits and quality assurance are conducted to check if your service is putting the policy and procedure into practice.

I hope my step by step suggestions are useful to those who are considering developing their own policies and procedures. Yes, it takes time and effort, but you will get something which truly matches your service, something which people recognise and something which is far more likely to be followed in practice.