Developing Policies And Standard Operating Procedures

(Robert Sarwono - Business Consultant of Trimitra Consultants)


New employees must learn about policies of the firm that apply to them. This article will address how policies and procedures presented as an integral part of the orientation and follow-up training processes are developed.

Policies Administrative tools that help employees attain the facility's goals. They describe what is to be done and why it is to be done.

Procedures A description of the process or actions that comprise the commonly accepted ways to perform routine or repetitive tasks. Procedures are developed by administrators and are used by all personnel to help ensure that policies will consistently be carried out.

Steps in Development

A formalized and sequential process can be used to develop policies and procedures. Let's review these steps.


Step 1: Define the Issue, Problem or Task

The process of developing a policy or procedure begins by recognizing the need for written information that addresses a facility goal or challenge. Common healthcare policies relate to personnel issues, the need to perform tasks in specific ways and to recognize health and safety concerns. Would the decision-making process be easier, fairer and/or more consistent if a policy was in place? Is the performance of a task so critical that it must be done by everyone all the time in the same manner? If the answer to these questions is "yes," a policy (in the first example) and a procedure (in the second case) are necessary.

Step 2: Determine responsibility for development

Many employee policies (i.e., those relating to vacations, holidays and sick leave) affect all employees and should be developed by administrators with company-wide responsibilities. Other policies (i.e., those relating to the management of items in inventory) are department-specific

Step 3: Develop a draft of the policy or procedure

Policies and procedures are usually developed by a team. While a specific author must be identified, input from affected personnel will likely be helpful. Depending upon the policy or procedure being developed, information from the manufacturers of equipment and supplies or the staff members at all organizational levels can be beneficial. Employees for whom policies will apply and those who must perform tasks described in an operating procedure are normally consulted as policies and procedures are developed or revised.

Step 4: Use an Agreed-Upon Template
Typically, policies and procedures used standard components (elements) to help provide necessary consistency and usefulness.

Step 5: Review and Analyze the Policy/Procedure Draft
Legal advice may be necessary to assure that a policy is consistent with relevant laws. The Board may sometimes become involved to assure that a policy fully supports the organization's mission, goals and objectives. Those with fiscal responsibilities may assess financial aspects of proposed actions. Ethical issues should also be considered, and other questions should be addressed, including: Is the policy or procedure reasonable? Are all requirements supported by need, facts and/or benefits? Is the policy or procedure consistent with existing policies or procedures? Can it be practically administered?

Step 6: Revise the Policy/Procedure Draft
The document must be written clearly and specifically. It is important to be declarative (i.e., the following procedure "shall" [not "may"] be used.). Abbreviations and acronyms should be spelled out at least the first time they are used. If a procedure is complex, a flow chart attachment may help the reader better understand each step.

Step 7: Conduct a Final Review
After the policy/procedure draft is revised and re-written as necessary (Step 6), an additional, final review may still be helpful. A new (proposed) procedure for new investments might be reviewed and modified, if necessary, by the firm Risk Management and/or Business Development Committees. Members should have provided input when the first draft of the document was written (see Step 3), but a final review that incorporates input from numerous other constituencies is also important.

Step 8: Make Final Revisions
The policy/procedure should be revised based upon a last round of additional input gained from the comments, recommendations and suggestions of those asked to contribute to the final review. (Step 7)

Step 9: Adopt the Policy/Procedure
After the policy or procedure is finalized, it should be adopted. The document now represents the firm's formal instructions about what is to be done and why it is to be done (if a policy) or about steps that should be used by all personnel to help ensure that the policy's intent is consistently achieved (if a procedure).

Step 10: Implement the Policy/Procedure
The document should be distributed throughout the firm after it is adopted. Implementation means that the document should be consistently used to guide all applicable personnel. Training may be required, and on-job training tactics should be revised, if necessary, to incorporate new procedures. Equipment, tools, supplies or other resources may need to be purchased as part of the policy or procedure implementation process.

Step 11: Utilize On-Going Evaluation/ Revision as Necessary
Policies and procedures should be reviewed at least twice a year because they can become out-dated, unclear or even contrary to current best practices. Evaluation/revision is a cyclical process.

In Conclusion
Managers conducting orientation programs for new employees must ensure that a wide range of policies and procedures are available and discussed, and those conducting orientation sessions must be certain that this information is understood. On-the-job compliance will be better assured because of the explanation and justification process provided by properly developed policies and procedures.

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