Surveyor Notes: Reviewing and Updating Your Policy Manual

Ted Markgren, CO (E), Senior Surveyor. 

The beginning of a new year offers an opportunity to do a bit of housekeeping around your facility. Reviewing and approving your policy and procedures manual is one of the most important activities to be performed. Over the years, policy manuals have a tendency to become stagnant. They become just another large manual sitting on the shelf collecting dust (literally or figuratively if your manual is electronic). Well, it is time to dust them off and conduct a thorough review of everything inside.

Where to begin?

A good starting point is to review changes to the ABC Facility Accreditation Standards. While there are seldom major changes to the standards, the changes do have an impact on your policies. Many policy manuals are based on the numeric order of the standards. Can you delete some of the policies that reflected standards that no longer exist? Do you have policies that reflect activities you no longer, or have never, performed in your facility? Delete them. You are held accountable for all of your policies regardless of whether they currently apply to your practice. If your policy manual includes documenting and fueling a delivery vehicle every evening and you don’t currently have a delivery vehicle, this policy not only doesn’t apply to you, but it puts you in violation of your own policy! Eliminate that which is not needed.

A large majority of facilities use a policy template that was purchased from one of many sources. Some are very old, others more recent. All feature a reference to an existing standard. Has your policy manual changed over the years to reflect the most current standards? Taking time to read and review your policy manual refreshes your knowledge of the standards and this, in turn, provides a better understanding of your company’s behaviors.

Involve your staff

One of the best ways to determine if your policies are applicable to your practice is to ask your staff. They are just as responsible for knowing the policies as are you. If staff behave differently from the policy, they either don’t know the policy or the policy is not being enforced. Change the policy or change staff behaviors, but don’t let either be out of sync with the reality of your practice.

The review process can seem tedious, but if it is conducted every year, the changes are few. Once your have competed the review, be sure to initial any changes and sign the document review page attesting that all polices are in place, in practice and current.