The Policy and Procedure Manual: Managing "By the Book"

By Paul Rao, PhD

Paul Rao, PhD, is Director of Speech-Language Pathology Service and Co-Director, Stroke Recovery Program, for the National Rehabilitation Hospital, in Washington, DC

Yesterday, a Policy and Procedure (P&P) manual might have been regarded, at best, as a dust collector to which one referred as a reference of last resort. At worst, it might have been used as a tool to slap an employee's wrist. Today, a P&P manual may be regarded as a living document of policies and procedures that form the foundation of any service delivery program, whether it be in a school, private practice, hospital, or other healthcare setting. The intent of this issue is to familiarize you with what commonly constitutes a P&P manual.


A P&P manual is required by accrediting, certifying, licensing, and regulatory bodies, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Commission on Accreditation of Rehabilitation Facilities (CARF), state licensing boards, state and local education agencies, and the Professional Services Board (PSB) of the American Speech-Language-Hearing Association. Is a P&P manual a must? Absolutely! The legal and regulatory climate alone has changed so rapidly during the last decade that a host of new policy areas have emerged. The most recent and perhaps most dramatic requirements relate to the Americans with Disabilities Act (ADA), [Public Law 101-336), which removes environmental, political and social barriers to individuals with disabilities. Are you prepared to comply with this welcome law and corresponding regulations? A P&P manual is designed to equip both employer and employees with a means to ensure compliance with all relevant rules and regulations.

What is a Policy?

According to the Bureau of Business Practice (BBP) (1988), "policy is a consistent guide to be followed under a given set of circumstances." The key word here is guide. A good policy will not lock you into rigid procedures or decision making. Rather, it will provide guidance for handling a wide range of organizational and programmatic issues, and will establish a framework for both management and staff decision making. According to the BBP, good policies are: broad, current, comprehensive, inviolate, written to specify responsibility for action, and used frequently. These attributes should be considered if you want policies that are user-friendly, and convey the mission, philosophy, and goals of your program.

What is a Procedure?

A procedure is a sequence of steps for completing a given activity. A procedure may outline the manner in which a particular policy is to be implemented, but it cannot take the place of that policy. Recall that a good policy is inviolate, that is, policies change slowly and infrequently if at all. Procedures, on the other hand, change often as dictated by any number of factors such as staffing, equipment, space, and technology. An earlier procedure related to a given policy may have required a number of steps which can now be eliminated as a result of new technology.

Why a Manual?

Policies and procedures must be documented in writing for several reasons, including the necessity to defend an action, a behavior, or a practice before an arbitration body. A P&P manual for your program provides the constancy necessary to deliver services in an efficient and logical manner. Memos and oral tradition are insufficient vehicles to disseminate policies and procedures. A P&P manual exists to answer the what and how of operations. It also meets one of the structural requirements of a quality improvement process. Without a P&P manual, it is likely that the responsible program would be cited by PSB, JCAHO, CARF, or other accrediting or licensing agencies for not complying with a standard. As is the case in medical record's parlance, so too with policies and procedures—"if it isn't written, it didn't happen." The presence of a P&P manual, however, is certainly no guarantee of quality, but without it, one could not become accredited.

Accreditation aside, a manager cannot operate effectively without written policies and procedures. While control of all management decisions may not be possible, a framework for decision making in important or particularly risk-prone areas (e.g, infection control) is necessary. Where employee or client safety is concerned, the need for a clear policy is paramount. In fact, JCAHO surveyors, as part of the standard hospital survey, are required to conduct random interviews with employees to ascertain their knowledge of an organization's fire and safety policy GCAHO, 1991). Thus, all policies must be available to all staff and written in such a way as to clearly specify the policy and procedures for a given issue:

You want your policy manual to be as clear as possible because it often plays a key role in court if an employee sues you for wrongful termination or any other labor dispute. Many courts around the country have ruled that a policy handbook often serves as a contract between employees and employer. (Applegate, 1991)

The P&P manual should not be designed to establish a set of rigid rules, but should be designed to enable managers to: a) appreciate how far the impact of their decisions might reach, b) encourage logical and consistent thinking; and c) provide an opportunity for all employees "to be singing from the same hymnal."

Documentation Format

A speech-language pathology and audiology (SLP/A) department within a larger institution will require an institutional P&P manual including all P&Ps that apply throughout the institution or to multiple departments within the institution (such as those pertaining to Fire and Safety, or Equal Employment Opportunity). P&Ps applicable to a single department only, such as a dysphagia assessment, are typically reviewed and approved by the appropriate department manager and responsible authority of the larger institution. 

At the National Rehabilitation Hospital (NRH) in Washington, DC, it is required that all P&Ps be reviewed every two years. In actual practice, P&P manuals are reviewed far more frequently as new equipment is installed, new product fines are incorporated, and innovations in client care are instituted. An outline of NRH responsibilities follows:

3.1 Senior Management (President, Vice President–Medical Director, Administrator, Associate/Assistant Administrators and Medical Directors)

  • Reviews and approves all institution-wide policies and procedures.
  • Assures that each policy and associated procedures have been appropriately reviewed and represent the Board's philosophy.
  • Assures hospital-wide compliance.

3.2 Service Director

  • Initiates, revises, reviews and approves all service specific policies and procedures and assures compliance with such.
  • Initiates, revises, reviews and recommends appropriate hospital-wide policies and procedures.
  • Informs subordinate staff of all policies and procedures.
  • Assures compliance with all policies and procedures.
  • Maintains an ongoing monitoring procedure for timely review and update of all policies and procedures.

3.3 Employees below Service Director level

  • Recommend new policies/ procedures and revision to existing policies/procedures to their Service Directors.
  • Comply with all policies and procedures.

3.4 Executive Secretary to Administrator

  • Assigns hospital-wide Policies and Procedures numbers, and distributes new and revised policies and procedures.

4.0 Applicability

  • All hospital personnel.

Responsibility is assigned to the director of speech-language pathology and audiology, not just to implement the P&P process, but to keep staff informed of new or revised P&Ps and to ensure compliance with all P&Ps. An outline of the NRH P&P documentation format follows:

5.1 Documentation Format

5.1.1 Hospital-wide policies and procedures shall be documented on the NRH Hospital Policies and Procedures letterhead (see Appendix A). The policy number is assigned by the Administrator's office.

5.1.2 All hospital-wide policies and procedures shall be documented using the following format: Section

Section 1.0 - Purpose
a positive statement of the intention or aim of the policy conveyed to the reader in as few words as possible.

Section 2.0 - Policy
a brief descriptive statement articulating the policy.

Section 3.0 - Responsibilities
an explanation of the policy and expectations of personnel who implement it.

Section 4. 0 - Applicability Section 6.0 - Procedures

Section 6.0 - References (if appropriate)

5.1.3 Additional sections may be added when appropriate. Documented policies and procedures shall always reflect original effective date and latest revision date.

5.1.4 Service-specific policies and procedures shall be documented on the NRH Practices and Procedures letterhead. Format should be consistent with that of hospital-wide policies and procedures. Procedure numbers are assigned by the individual service, using a numbered sequence which does not conflict with the hospital-wide policies and procedures numbering scheme.

Sample Table of Contents of a P&P Manual

Your P&P manual should, at a minimum, address all areas for which there is an accreditation standard. For example, prior to a PSB survey, the department manager must conduct a self survey and review the current PSB standards (ASHA, 1991). The speech-language pathologists' and audiologists' P&P manual should have a policy addressing each PSB standard under the following broad categories:

  • Program goals
  • Administration
  • Services
  • Personnel
  • Records
  • Physical plant and equipment
  • Program evaluation and quality improvement.

The JCAHO manual for Survey Preparation for Physical Rehabilitation Services (JCAHO, 1991) lists the following required P&Ps for hospital-sponsored ambulatory care services:

  1. Standing orders
  2. Consultant services
  3. Release of patients
  4. Patient Bill of Rights
  5. Appointment system
  6. Primary treating physician
  7. Panic values (eg, blood chemistry result indicates immediate action)
  8. Reporting communicable diseases
  9. Role in disaster
  10. Protection of valuables
  11. Specific procedures, specific location, specific practitioner
  12. Privacy and confidentiality

For general and "non-bed therapy" services, the JCAHO (1991) outlines additional required P&Ps:

  1. Special procedures including code
  2. Documentation requirements
  3. Safety
  4. Infection control
  5. Equipment, initial inspection and preventative maintenance

Your P&P manual will be unique to your program, but should contain the required minimum P&Ps that are common to all departments. You, therefore, must be familiar with all current accreditation, licensing and regulatory requirements so that the department's P&P manual is up-to-date and reflects current practices. Updates of standards or regulations are available (usually free or at nominal cost) from each accrediting body or licensing /regulatory agency. For example, you may now purchase the JCAHO's 1992 manual which has fewer standards when compared to the 1991 manual.

Because the survey process can be a "moving target," so a good manager keeps documentation of policies and procedures complete and current, and is prepared for any and a survey queries and approaches. For example, as recently as 1987, the JCAHO was emphasizing the outcome component of quality assurance. Today, the JCAHO is espousing continuous quality improvement with a greater emphasis on work processes which will lead to desired outcomes. In a pre-survey checklist, the JCAHO (1991) lists a number of 'Items To Remember' for a rehabilitation facility:

  • All licenses (Medical staff as well as other professional staff)
  • Patient rights and responsibilities form (Has it been updated with new requirements?)
  • Abbreviation list (for medical procedures, etc.) updated and utilized
  • Annual review and update of quality improvement plan, utilization review plan, safety/risk management plan, hazardous waste plan
  • Required in-services carried out, including those for hazardous waste
  • Policies and procedures books up-to-date and reviewed in accordance with standards, Le, yearly, every other year, every three years
  • Medical staff bylaws – annual review and update
  • Governing board bylaws – every other year review and update
  • Disaster plan update and at least annual disaster and fire drills carried out
  • Exit sign lights work, fire walls do not have holes above ceiling, fire doors do not gap
  • Incomplete chart counts (for as long as 120 - 90 - 60 days)
  • Mission statement for rehabilitation
  • Documentation of evidence of nursing participation in budget process
  • Documentation of mechanism enabling nurses on units to know what each physician can do in facility
  • Nursing competency reports to Board of Directors
  • Check contracts and policies for dates
  • Confidentiality policy and procedures
  • Patient complaint/resolution policies
  • Physician continuing medical education related to rehabilitation
  • Annual quality improvement evaluation for each department and program as a whole
  • Check refrigerators for food in medication refrigerators or outdated and unmarked/ undated food
  • Temperature checks on refrigerators and freezers
  • Gas lines checked after constructions
  • Non-compliance report form

Policies and procedures play a prominent role in the JCAHO survey process. The same can be said for PSB surveys, wherein surveyors may spend as much as 10% of their time reviewing P&Ps. Half of the battle in preparing for a survey is getting your P&P manual in tip-top shape.

Policy Writing Tips

The Bureau of Business Practice (1998) offers some useful tips for defining policies and procedures:

  • Keep your sentences short, but don't make them sound choppy.
  • Avoid terminology that will not be readily understood by all readers. Remember that the policy is to be used throughout the organization. Terms familiar to staff in Personnel may be unfamiliar to someone in Accounting.
  • Use the pronoun "you" whenever possible. Third-person references are certainly more appropriate when making corporate policy statements, but personnel policies that apply to everyone or that deal with situations common in almost every department should be couched in more familiar terms.
  • Avoid fuzzy wording and innuendo. Say exactly what you mean, in everyday language, rather than risk the possibility of being misinterpreted.
  • Don't go overboard on lists and outlines. There are some policy areas in which a list or outline is a good way of covering all the bases, but when used to excess they can make for dull reading (or a bad policy).
  • "Humanize" legalistic policies. With the intention of complying with the law as closely as possible mimicking legal language. While it may make a policy sound more authoritative, it can also rob it of its effectiveness by discouraging the uninitiated reader. One way of humanizing a legal policy is by referring directly to the people involved and the actions they should take.
  • Use active voice where possible. Many writers use the passive voice to sound more authoritative and impersonal. But using only the passive voice can make a policy sound unnecessarily dull and pompous.
  • Always revise your first draft. It is only by going over what you have written two or three times that all unnecessary words can be eliminated.


A P&P manual is perhaps the single most important tool for managers. This article defined policies and procedures, explained why they must be documented, and outlined the need for a P&P manual.

A table of contents and documentation format, which address accrediting, licensing, and regulatory requirements were illustrated. Accreditation standards were referenced and a pre-survey checklist was provided to highlight specific areas needing policies and procedures. Finally, writing tips were offered to encourage documentation that is not only organized and logical, but readable and user-friendly.

In summary, a P&P manual should fulfill three basic functions. It should:

  1. Enunciate clearly the departments and the institution's mission, philosophy and goals;
  2. Delineate all ethical, strategic and organizational parameters within which the department interacts with its employees, and
  3. Provide a sound framework for logical and consistent management decisions.


I wish to express my appreciation to Dr. David Resnick for his assistance with this manuscript and for mentoring me these many years on 'managing by the book.'


American Speech-Language-Hearing Association, Council on Professional Standards, (June/July, 1991). "Accreditation of Professional Services Programs Proposed Standards Revision." Asha, 49–52.

Applegate, Jane. (September 23, 1991.) "Succeeding in small business." Baltimore Evening Sun , Baltimore, Md.

Bureau of Business Practice. (1988). Personnel Policy Manual . New Jersey: Prentice Hall.

Joint Commission on Accreditation of Health Care Organizations. (August 1987). Overview of the joint Commission's "Agenda for Change." JCAHO Document. Chicago, IU Author.

Joint Commission on Accreditation of Health Care Organizations. (1991). Survey Preparation for Physical Rehabilitation Services (2nd Edition). Oakbrook Terrace, IL Author.

National Rehabilitation Hospital. (1991, June). Policy and Procedure on Policies and Procedures, #700.00. Washington, DC: Author.

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