Developing a policy and/or procedure

In general practice it's often useful to also understand how a policy will happen (procedure), so we've combined those two here. Below is a policy/procedure structure that can help practices write content suited to them. This format is a suggestion, but it helps to know that assessors will look for the main areas outlined below when they’re reviewing work as part of our Quality Programmes. Check with your PHO too because they might also have resources to support you in creating your own bespoke policies and procedures.

How to structure a policy and/or procedure

These are the key elements to consider when drafting a policy and/or procedure

  • Your practice name and logo

    Adding your practice's name and logo lets people know who owns the policy/procedure

  • The title of the policy/procedure

    Create a descriptive name that is clear and easy to understand. Avoid acronyms or jargon and try to consider how naming is in a way that's easy to find later.

  • Application of the policy

    Who does this policy apply to? Is it your patients? Or your staff? Be clear about which groups this relates to.

  • Purpose and intended outcomes

    Write a very brief statement to clarify the reason for your policy/procedure.

  • Definitions of terms

    If there are any terms/words uses in your document that you think might not be understood by everyone then this is a good place to outline those. A good example might be clinical language.

  • Processes and procedures

    Describe here how the policy is going to be carried out. You might consider key elements (refer to The Foundation Standard guidance), timelines, the roles and responsibilities of team members (use job titles rather than names), and you should refer to and adhere to the applicable legislation.

  • Key relevant documents

    In your policy you should also reference (or include) as needed: legislation, regulations, policies, procedures and standards, guidelines, forms, and any other useful resources.

  • Document control

    Your policies and procedures should be well documented so that others understand who developed and worked on them. You should include who the policy was prepared by, who approved it, the date that happened and who owns and manages it. You should also add page numbers and include a date for the policy's review - the maximum review period is 3 years, or earlier as required.

Remember to build in an audit process

Clinical policies and processes where there is potential risk for patients need to be regularly audited to make sure they’re being adhered to.

These policies/procedures include:

  • A documented clinical correspondence and investigations policy and procedure (5.1).
  • A documented repeat prescribing policy and procedure (9.1).
  • Documented standing orders policy and procedures (9.2).
  • A documented medicine reconciliation policy and procedure in accordance with the Health Quality and Safety Commission Medical Reconciliation Standard 2012 (9.3).
  • Infection control and healthcare waste policies 12.1 and 12.2.

Also in this category

Quality Programmes resources

Quality Programmes brochure

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Quality Programmes resources

Foundation Standard - list of training requirements

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Quality Programmes resources

Purchasing a Cornerstone module

Step by step guide explaining how to purchase a Cornerstone module.

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