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Policies: Say What You Do and Do What You Say

Accreditation Monthly, August 26, 2009

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There is sometimes a tendency to want to write everything down in great detail, but more may not be better when it comes to writing policies. Organizations often receive Joint Commission RFIs due to language in their own policies. Consider the following guidelines for writing policies.

Q: Do we need this policy?
A: A policy is needed if:

• It is specifically required by an accrediting or regulatory body (e.g., Joint Commission, CARF, CAP, DHR, or CMS).
• Specific guidelines are needed to direct decision-making or completion of an activity or function (particularly high-risk, low-volume activities).
• There is a widespread and repeated problem and pattern of actions that are inconsistent with the institution's values. Even then, there should be a period of questioning whether the problem is best addressed by a policy or through some other intervention.

Q: What are the characteristics of an ideal policy?
A: The ideal policy will:

• Be brief and include only the information needed to convey the key message or steps
• Reflect what will be done, not what the organization hopes will happen
• Follow the natural flow of the process to enhance compliance
• "Say what we do and do what we say"
• Avoid requirements that are more extensive than regulatory or accreditation standards
• Be developed with input from those who are impacted by the policy (staff members, other departments, physicians, etc.)
• Not conflict with system policies

Q: What are some specific policy-writing tips?
A: For starters:

• Keep sentences short (average of 10–12 words)
• Use clear, concise, easy-to-understand language
• Use the active voice (e.g., "assess the following" instead of "the patient will be assessed")
• Be consistent with verb tense throughout
• Whenever possible, link attachments to online forms on the intranet
• Exclude the following documentation in the body of the policy:
  • Staff education material (consider alternatives such as CBLs, PowerPoint presentations, or competency checklists)
  • Forms and instructions
  • Flow charts
  • Communication to a specific department regarding an infrequent occurrence

Remember, policies are ineffective if they are over-engineered or too wordy. Policies are not meant to be all-encompassing or a substitute for individual judgment and training.

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