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MCN Healthcare’s Policy Management Series: Policy and Procedure Development

MCN Healthcare’s Policy Management Series: Policy and Procedure Development

Does writing policies and procedures send you in a frenzy? Does it send you running from the building? Or for the hills?

Developing policies and procedures is time consuming. Research must be performed, subject matter experts consulted, and review and approval by appropriate leadership staff must be completed. Staff must then be educated on the policy and procedure and FINALLY the policy and procedure can be implemented.

Writing policies and procedures shouldn’t be anxiety inducing. It can be accomplished! MCN’s Policy Management Series will speak to the development of policies and procedures, the approval process, education of staff, implementation, and document control.

Why do we have policies and procedures?

Policies and procedures provide the framework for healthcare organizations and standardize patient care and operations. When developing a policy and procedure, federal, state, and local regulations, accrediting organization standards, evidence-based practices, and organizational administrative decisions must be reviewed and taken into account.

Healthcare organizations must define, document, and maintain processes in well written procedures to ensure compliance with regulations and standards and for operational requirements in order to provide high-quality patient care, manage risk, and improve performance.

To be effective, policies and procedures must be easily understood by the individuals who are affected. It is important that staff comprehend the content and can comply with the policy and procedure. Policies may be departmental, cross-departmental, organization-wide, and/or multi-disciplinary, which can add an additional layer of complexity.

We know that writing policies and procedures is not everyone’s favorite thing to do! MCN has been writing healthcare policies and procedures for 30 years, and this is what we have learned.

General Policy and Procedure Guidelines

  •  Ensure your policies are as clear and concise as possible.
  • Use concise titles that are readily recognized and searchable. The title must reflect the content of the P&P. Do not name a policy the same name as a department or include a number in the title that someone used years ago when they created a numbering system. Don’t use the word “policy” in the title.
  • Define terms to avoid misinterpretation.
  • List equipment and supplies.
  • Some organizations use purpose statements other do not.
  • Write a clear and simple policy statement. Policy statements describe how the healthcare organization provides care, treatment, or services.
  • Describe the procedure by writing “how” the policy is accomplished. The procedure should include the steps (workflow) to take in order to comply with the policy.
  • Check federal, state, and local laws, CMS regulations, and accrediting organization standards. Remember: the more stringent regulations/standards must be followed.
  • Use evidence-based practices from established professional organizations and peer-reviewed journals.
  • When updating a policy, check that references are current and that the policy reflects any changes. List references at the end of the policy per your organization, and standardize the format used for references (e.g., American Psychological Association [APA]).

Policy and Procedure Template

  •  A standardized template should be used throughout the organization. Laboratory Department headers may be different due to regulatory requirements.
  • All headers may contain the organization’s logo, the title of the P&P, Department/Scope, Owner, number of pages (e.g., 1 of 3), and any other information identified by the organization. This information may differ if you are using policy management software. (DNV – NIAHO requires reviewed/revised dates and description of changes on each policy.)
  • Determine a standard format for bullets and/or numbering, as well as for font (Arial 12 point is recommended) and margins (1″).


  • Use evidence-based practice information.
  • Acronyms should be spelled out the first time followed by the acronym in parenthesis. For example: The Centers for Disease Control and Prevention (CDC).
  • Standardize language, be clear and concise, and choose words carefully. Write the procedural steps in an active voice.

Look for our next blog where we will discuss the policy and procedure approval process.

MCN Healthcare’s Policy Library includes more than 18,000 customizable policies and procedures authored by MCN clinical staff. Take a look!


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