Effective Date: 
Sun, 09/01/1996
Thu, 02/08/2018
Mon, 08/01/2011

Policies and Procedures (P&Ps) provide direction, guidance and oversight for Health Center operations.
 Processes which typically require a policy and procedure are:

  •   high-volume
  •   high-risk
  •   high-cost
  •   problem-prone
  •   regulatory-required
  •   new
  •   Policies and procedures are aligned with the Accreditation Association for Ambulatory Health Care (AAAHC) standards.
  •   All staff are familiar with the Policy and Procedure Manual, its contents and its location.
  •   All staff observe Policy & Procedure in the course of their job duties. P&Ps are intended to address the majority of situations. Unusual situations will occur, for which the P&P is deemed inapplicable. In this instance, the staff member notifies his or her supervisor of action taken outside of policy and/or documents the situation and actions taken.
  •   The Executive Director has overall responsibility for the Policy and Procedure Manual. Individual managers and supervisors have delegated responsibility for P&Ps related to their operational areas.

P&Ps include a policy statement and a procedure description. Key points may also beincluded.
The policy section describes what, why, and who, and includes:

  •   Statement of intent
  •   The purpose of the P&P; the usual/expected action or outcome of the P&P; the standard which is met by the P&P

Policy title: Policy and Procedure on Creation and Maintenance of Policies and Procedures

  •   Authorized staff
  •   Who is responsible for performing the procedure.
  •   Designated responsibility
  •   Identify by title the person or persons responsible for oversight of the process or subject of discussion.

The procedure section describes how and when, and includes a general outline, steps, directions, actions and components of the process under discussion. More specific details, for example the exact operation of a particular piece of equipment, operator’s guidelines for particular functions, or clinical management protocols, may be developed by individual supervisors/departments and referenced by the general policy.
Key points are bulleted items that emphasize and summarize important elements of the P&P. The inclusion of key points is optional.

2. Policies & Procedures are sorted into categories called Volumes and numbered sequentially within the category. Sub-categories may be designated for specific departments. Volumes include:

  •   Administration
  •   Clinical Services
  •   Support Services
  •   Facility
  •   Personnel
  •   Health & Safety

3. Creation of P&Ps:
Managers and supervisors create P&Ps for processes which are regulatory-required, problem-prone, high risk, high volume, high cost, or new. P&P creation includes collaboration with the process owner(s), who review and endorse the document.

4. Review, Approval and Distribution:

  •   Draft P&Ps are sent to the Executive Director for final approval, include notation of persons or groups that have reviewed and preliminarily approved the document.
  •   P&Ps are reviewed and approved by the Executive Director. Approval is documented in the Approval Log, which is maintained in the Director’s office as part of the Policy and Procedure Manual.
  •   Approved P&Ps are readily available to all staff as hard copy manuals &/or in electronic format.
  •   P&Ps are reviewed and updated by the responsible managers and supervisors. The Executive Director reviews and approves the updated Manual annually.

5. Guidelines for policy wording:

  •   P&Ps are written in the present tense i.e. “are responsible” instead of “will be responsible.” Full Manual Page 20

Policy title: Policy and Procedure on Creation and Maintenance of Policies and Procedures

  •   Titles are used in place of names i.e. “Director” instead of “Dr. Smith.”
  •   Brief, clear statements are used whenever possible instead of lengthy discursive text. Outline or bullet format is used as appropriate.
  •   Pertinent reference materials, associated forms, etc. are identified and attached.
Key Points: 

Student Health Center employees observe policy and procedure guidelines in their job functions. Variations from policy are communicated to the supervisor and/or documented.

  •   The Executive Director has overall responsibility for the Policy and Procedure Manual.
  •   Managers and supervisors have responsibility for Policy and Procedure in their operational areas.
  •   Policy and Procedures are readily available to staff.
  •   The Policy and Procedure Manual is reviewed and updated annually.