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 logoAdding your practice's name and logo lets people know who owns the policy/procedure
The title of the policy/procedureCreate 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 policyWho does this policy apply to? Is it your patients? Or your staff? Be clear about which groups this relates to.
Purpose and intended outcomesWrite a very brief statement to clarify the reason for your policy/procedure.
Definitions of termsIf 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 proceduresDescribe 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 documentsIn your policy you should also reference (or include) as needed: legislation, regulations, policies, procedures and standards, guidelines, forms, and any other useful resources.
Document controlIt's a good idea to do some housekeeping on your policy/procedure so that people after you can navigate the document and also understand who worked on it. You should include who the policy was prepared by, who approved it and the date that happened, who owns and manages it. You should also remember to add page numbers. Also include a date for the policy's review - the minimum period for that is generally three-yearly.
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.