What is a Policy?

A policy is a set of clear expectations that an organisation publishes. Policies can be rules or guidelines relating to the conduct of employees. At the same time, they state the principles that the organisation’s clients, patients or residents can hold staff accountable for (Ausmed 2022).

A policy and its associated procedures guide the way staff undertake their roles. A policy aims to prevent variation in practice, which is critically important in clinical practice to safeguard positive health outcomes and experiences for people in our care.

Why do I Need Policies?

Policies contribute to a safe environment by mitigating unwarranted clinical variation. Policies aim to prevent clinicians from engaging in areas of practice that vary from best practice. Consistency across an organisation is critical. Policies guide the organisation, influencing and determining all major decisions and actions, and reduce liability risks (PowerDMS 2020a).

Policies Translate Processes into Practice

Policies are essential for translating an organisation's systems and processes into practical, actionable steps for staff. They are key to the effective operation of quality systems and the provision of high-quality care. Policies are particularly vital when addressing gaps in knowledge, skills or practices that do not stem from a lack of education but rather from inconsistencies in following specific processes or procedures.

What Are the Regulatory Requirements for Policies?

Policies are central to safety, quality, risk management and evidence-based care. In any health or aged care standard, there are clear regulatory requirements for creating, maintaining and regularly reviewing policies. Policies are intrinsically linked to the core need for organisations to ensure systems are in place within health service organisations to maintain and improve the reliability, safety and quality of healthcare.

From a regulatory perspective, policies are described alongside governance, leadership and culture, patient safety, risk management, and quality improvement. These concepts are non-trivial for organisations, highlighting the importance of policies and an effective policy management system.

Strengthened Aged Care Quality Standards

Specifically, in the strengthened Aged Care Quality Standards, within Standard 2: The Organisation, outcome 2.3 Accountability and quality system, it’s clearly stated that:

‘The provider maintains and implements policies and procedures that are current, regularly reviewed, informed by contemporary, evidence-based practice, and are understood and accessible by workers and relevant parties.’

National Safety and Quality Health Service Standards

Within the National Safety and Quality Health Service (NSQHS) Standards (2nd edition), the regulatory requirements for policies sit with the Clinical Governance Standard (Standard 1). Action 1.07 states ‘the health service organisation uses a risk management approach to:

• Set out, review and maintain the currency and effectiveness of policies, procedures and protocols,
• Monitor and take action to improve adherence to policies, procedures and protocols,
• Review compliance with legislation, regulation and jurisdictional requirements.’

(ACSQHC 2021)

What’s the Difference Between a Policy, Procedure, Protocol and Process?

• Policy: A policy is a set of guiding principles or rules that outline the expectations and standards for behaviour or practice within an organisation.
• Procedure: A procedure is a detailed, step-by-step guide for performing a specific task or activity to meet the standards set by the policy.
• Protocol: A protocol is a specific plan or set of instructions to be followed in particular situations, often within clinical settings, to ensure consistency and safety.
• Process: A process is a series of actions or steps taken to achieve a particular outcome, often encompassing several procedures and protocols within its scope.

(PowerDMS 2020)

How Big Does a Policy Library Need to Be?

The size of a policy library depends on the scope and complexity of the healthcare organisation. While it’s crucial to cover all necessary areas, it’s equally important to avoid redundancy. Each policy should serve a distinct purpose and contribute to the organisation’s overall goals, ensuring that the library remains comprehensive yet manageable.

What Policies Do I Need?

Determining which policies are necessary can be challenging, particularly if you are new to quality management or your organisation is just beginning to establish its policy framework. Each service must assess its unique scope and setting to determine the most appropriate policies (PowerDMS 2020a).

However, there are typically several key types of policies that most healthcare services should consider implementing:

Policy Type	Description
Patient Care Policies	These guide how to manage medical situations, including safe medication management, infection prevention, and handling emergencies. Tailor them to the types of patients you serve, whether in aged care or a hospital setting.
Workplace Health and Safety Policies	Covering PPE, exposure to hazardous substances, manual handling, and staff wellbeing, these policies ensure a safe environment for both staff and patients.
Data, Privacy, IT, and Security Policies	These address secure documentation, communication, and data protection, including social media guidelines and patient privacy protocols.
Administrative, Ethical, and HR Policies	These manage HR issues like leave and shift changes, visitor policies, and overall ethical guidelines to ensure consistent operations and decision-making.

These core policies help establish a solid foundation for quality management in your organisation. Choosing a policy platform that supports collaboration with policy partners can further enhance this foundation, ensuring that policies are effective, accessible, and aligned with your organisation's goals.

How Do I Create Policies?

Policies should be consistent in format and written in clear, common language for easy understanding by all staff. This ensures that everyone, regardless of their role, can comprehend and implement the policies effectively.

Steps Involved in Creating a Policy

1. Establish a policy team or group.
2. Determine the specific issue or area that requires a policy based on your organisation’s goals, regulatory requirements, or identified risks.
3. Collect relevant data, review best practices, and legal requirements to ensure the policy is well-informed and comprehensive.
4. Draft the policy in clear, concise language, following a consistent format. Your test should be that any staff member can understand it.
5. Engage with stakeholders, including consumers, to ensure it meets organisational needs.
6. Make necessary revisions based on feedback to refine the policy and ensure it meets all requirements.
7. Obtain formal approval from the appropriate authority or governance body within the organisation.
8. Distribute the policy to all relevant staff, ensuring they are aware of its content and implications for practice.
9. Regularly review the policy to ensure it remains current and effective, making updates as needed.

How Do I Manage and Review My Policies?

The work doesn’t stop once you have created your policies! From here, effective policy management requires maintaining a comprehensive policy register to track your coverage of polciies against regulatory Standards, which is a significant benefit of using tools like Ausmed Policy Management.

When reviewing policies, using tools like Microsoft Word allows for easy editing, reviewing, and approval. When updating policies, it's essential to keep a record of changes and ensure the staff-facing version is current. Clearly note what has changed and how staff were notified to maintain transparency and compliance.

How Often Do Policies Need to Be Reviewed?

Policies should be reviewed regularly to ensure they remain current and effective. The frequency of reviews can vary, but a common standard is to review policies annually or whenever there is a significant change in regulations, practices or organisational structure.

Additionally, an organisation's clinical governance or quality teams may define specific intervals for different types of policies based on their risk levels. For example, policies related to high-impact, high-prevalent clinical care areas, such as falls, pressure injury prevention, or delirium, may be reviewed on an annual basis. In contrast, policies on topics like team communication might be reviewed less frequently.

Steps for Reviewing a Policy

Establishing a policy review cycle is an essential aspect of policy management. Policy reviews typically involve the following steps:

1. Assessment: Evaluate the current policy’s effectiveness and relevance.
2. Consultation: Gather feedback from staff, stakeholders and experts. Increasinbly, this is including consumer (patient) representatives.
3. Revision: Update the policy to reflect new information, evidence, regulatory changes or feedback.
4. Approval: Submit the revised policy for approval by the appropriate governance team or department.
5. Communication: Distribute the updated policy to all relevant parties, notably staff, and ensure it is accessible and acknowledged in a timely manner.

Maintaining Compliance with Policies

How Do I Ensure Staff Read and Understand Policies?

Employees need to acknowledge policies so that each person can be held accountable for maintaining expectations and the organisation can obtain the safety and compliance requirements it seeks.

Most policy management systems enable the core feature of staff acknowledgment. Some systems, like Ausmed’s Policy Management System, can place policies alongside relevant learning modules to build the required knowledge and skills. Additional strategies to generate a robust policy acknowledgment experience include quizzes to test understanding, linking policies to learning requirements, and incorporating competency assessments to validate practical applications.

What Happens if I Get Audited or There is an Incident? What Information Will I Need?

When appropriate policies and procedures are in place within an effective policy management system, navigating an incident or an audit becomes much easier. Clear procedures guide employees and managers on the necessary actions during an incident, helping to manage the situation effectively. Reviewing these policies and incident reports can also help leadership identify what went wrong and prevent future occurrences.

During an audit, accurate and comprehensive reporting is crucial. With tools like Ausmed, ample evidence can be quickly and easily generated, ensuring you’re well-prepared for any audit or review.

Creating, reviewing, and having staff acknowledge policies, and demonstrating ongoing compliance with polciies is most effectively achieved within a dedicated policy management system.

What Happens if a Staff Member is Practising Outside of Policy?

If a staff member is practising outside of policy, it can lead to significant risks, including patient safety issues, legal liabilities and regulatory non-compliance. The organisation should have a clear process for addressing such incidents, which may include:

• Investigation: Conducting a thorough review of the incident.
• Corrective action: Implementing measures to prevent recurrence, such as additional training or disciplinary action.
• Reporting: Document the incident and report it to relevant authorities if required.

How Do You Monitor Compliance with Policy?

Ensuring that policies are adhered to requires a multifaceted approach. Regular training and education are crucial to keeping staff informed about the policies and their importance, helping to embed these guidelines into clinical practice. Conducting regular audits and inspections is another key strategy, as it allows for monitoring compliance and identifying areas that may require improvement.

Additionally, establishing clear reporting mechanisms ensures that non-compliance or issues can be quickly identified and addressed. Creating feedback loops where staff can share their insights on the practicality and effectiveness of policies helps refine and continuously improve the policy management process. Technology can also play a role, with digital policy management systems offering tools to track policy acknowledgment and adherence in real-time.

What is a Policy Management System?

A policy management system is a way to organise, distribute, and record staff acknowledgement of an organisation’s policies. An effective policy management system helps users create and revise policies and procedures to ensure they are informed by current, contemporary, evidence-based practices and regularly reviewed.

An effective system also reduces the administrative burden associated with managing a policy library for both the system's organisational manager(s) and staff required to access, acknowledge, and follow the organisation’s policies.

What are the Benefits of a Policy Management System?

Policies serve as a critical tool for ensuring that staff can effectively implement an organisation's expectations, systems and processes in their daily work. They play a vital role in several key areas, including reducing legal liabilities by ensuring that the organisation adheres to regulatory requirements while delivering consistent, high-quality care to patients. The benefits of well-managed policies include:

• Safety: Policies specify the scope, standards and expectations of particular clinical skills or workplace requirements.
• Compliance: They provide an organisation with a means to gain assurance through staff acknowledgment, ensuring that everyone is aware of the expectations, scope and specific requirements of their tasks, activities or roles.

Selecting an Effective Policy Management System

When selecting a policy management system for a healthcare environment, it's important to ensure the system has specific capabilities to be truly effective. These include:

• Support remote access: The system must allow staff to easily access the latest policies remotely when required, ensuring there are no outdated or duplicate versions in circulation and that policies and procedures are available at the point of care.
• Provide evidence of acknowledgment: It should be able to provide evidence that staff have acknowledged the policies, which is crucial for audits, internal investigations and performance reviews.
• Map policies to standards and roles: The system should contain an accurate policy registry and be able to map policies to job roles and Standards, ensuring that staff are aware of the policies that directly affect their responsibilities.
• Track version control: It must track and maintain a version history of policy updates, showing when and how these updates were distributed to staff, thereby supporting audit controls.

Who is Responsible for Policy Management?

At the highest level, the governing body, such as the board of an organisation, holds ultimate accountability for the quality of care and services provided. This governing body is responsible for maintaining oversight of all aspects of the organisation’s operations, including the quality system that drives continuous improvement in care and services (ACQSC 2023)

Specifically, the administration, creation and ongoing management of policies are typically prioritised within the organisation’s quality framework, with a dedicated quality team executing these tasks. Alternatively, the responsibility for certain policies may be shared depending on their lifecycle; for example, an education or clinical-based team may create a policy while the quality team maintains it. The size and structure of the organisation often determine how these responsibilities are shared or delegated.

Quality and education teams must collaborate closely to ensure that their core outputs—policy management and education and training initiatives—are aligned to support the organisation's overall goals.

What Are the Challenges Associated with Policy Management?

Policy management has challenges, as organisations must navigate a range of obstacles to ensure effective implementation and compliance. These challenges include:

• Complexity of regulations: Healthcare regulations are often complex and frequently updated, requiring continuous policy adjustments.
• Staff engagement: Ensuring all staff are aware of, understand and adhere to policies can be difficult, especially in large organisations where the need for new policy acknowledgement is frequent.
• Consistency in application: Variability in how policies are implemented across different teams, scopes of practice, and departments can lead to inconsistencies in care and service provision.
• Policy overload: Managing an extensive policy library can be overwhelming, and distinguishing between necessary and redundant policies is critical to reducing ‘policy burnout’.

How Does Policy Management Align with a Quality Management System?

Policy management is an integral component of a broader quality management system (QMS). Policies provide the foundation for standardising processes and ensuring that quality standards are met consistently. They align with other elements of a QMS, such as risk management, incident reporting and continuous improvement, to support the overall objective of providing high-quality care.

What’s the Relationship Between Policies and Education?

Do Staff Need Training on How to Follow Specific Policies?

Yes, staff need training on how to follow specific policies to ensure they understand the expectations, procedures and protocols outlined. Training should be tailored to the specific roles and responsibilities of staff members, ensuring that they are equipped with the knowledge and skills necessary to apply the policies in their practice.

How Do Policies Differ From Education?

Policies and education are different tools an organisation can use to achieve the desired result of high-quality care. They are intrinsically linked, and when their respective owners (teams that lead education and policy development) are aligned, organisations can reap the benefits. Effective education ensures that staff understand and can apply relevant organisational policies in their practice by having the relevant knowledge and skills. Conversely, policies can inform the focus of educational initiatives by highlighting areas where knowledge or skills need improvement.

How Can We Link Policies and Education?

Linking policies and education can be achieved through several approaches. One effective method is to incorporate policy awareness into regular educational sessions, ensuring that staff are consistently informed about the latest policies, any changes to them and how they apply to their practice.

Additionally, it is essential to regularly update education and training activities to reflect any changes in policies, ensuring that staff maintain ongoing competency and are always aligned with the organisation's expectations and that staff continue to practice within the organisation’s policy scope.

Conclusion

Policies and an effective policy management system are critical functions that support healthcare organisations to provide safe, consistent and high-quality care and comply with regulatory standards. By addressing the challenges associated with policy management, aligning it with quality management systems and linking policies to education, providers can significantly improve the quality of their services and meet the regulatory requirements of the relevant standards in Australia.

Related Resources

Improving policy management is an ongoing process. Here are some other helpful resources to consider:

• How Organisations Can Create Policies That Actually Improve Care
• The Do's and Don'ts of Policies in Healthcare
• Policies and Procedures in Healthcare

References

• Ausmed 2022, ‘The Do’s And Don'ts of Policies in Healthcare’, Ausmed L&D Toolbox, 7 July, https://www.ausmed.com/publish/organisations/guides/policies-in-healthcare.
• Australian Commission on Safety and Quality in Health Care 2021, National Safety and Quality Health Service Standards, Australian Government, https://www.safetyandquality.gov.au.
• Aged Care Quality and Safety Commission 2023, Final Draft Strengthened Aged Care Quality Standards, Australian Government, https://www.health.gov.au/resources/publications/the-strengthened-aged-care-quality-standards-final-draft?language=en.
• Aged Care Quality and Safety Commission 2023, Provider Governance, Australian Government, https://www.agedcarequality.gov.au/for-providers/provider-governance.
• NDIS Quality and Safeguards Commission 2021, NDIS Practice Standards and Quality Indicators, Australian Government, https://www.ndiscommission.gov.au/sites/default/files/2022-02/ndis-practice-standards-and-quality-indicatorsfinal1_1.pdf.
• iSB Group 2023, ‘HSEQs: How Often Should Health and Safety Policies be Reviewed?’, iSB Group Blog, 16 February, https://blog.isb-group.com/hseqs-how-often-should-health-and-safety-policy-be-reviewed.
• PowerDMS 2020a, ‘What is a Policy vs. a Procedure?’, PowerDMS, viewed 5 September 2024, https://www.powerdms.com/policy-learning-center/what-is-a-policy-vs.-a-procedure.

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