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Policies and Procedures: What’s In Your Manual?

Dan Thorne • Oct 14, 2021

Policy and procedure manuals are like trophies: people collect them, and then after a while, they simply take up space. If a person walked into your office or saw you in a Zoom meeting, how many policy manuals would they see behind you? It’s common to have 10, 20, or 30 manuals, all addressing different topics or departments.


Having a lot of policy manuals may make a leader feel important or valuable, but they are no longer necessary. But here are a few questions to ask yourself about your manuals:


1.     Is it valuable if the information is outdated by months or years and gathering dust?

2.     If no one is going to look at the manual, whether they be the leader, an employee, or a regulatory agency, why is it there?

3.     If someone is going to look at it, is it concise and organized?

4.     Can it be streamlined, uploaded to a server, or consolidated with other manuals?

5.     If someone important (regulatory or accreditation-based) looked at it today, would you receive deficiencies due to inaccuracy or missed requirements?


If your organization is part of a large corporation that requires you to have certain manuals for Safety, Human Resources, Infection Control, etc., then it might be out of your control. But it couldn’t hurt you to suggest that the powers that be that killing all the trees for paper is not necessary and they can be stored on a server. The only time many organizations need the manual is when a surveyor is there, and then it can be printed out for them. Otherwise, the manual can be stored in a cloud or the server.


Suppose your office has a manual for Medi-Cal or Medicaid; a manual for an accreditation agency such as Joint Commission, CARF, or COA; and a manual for the staff. Shouldn’t they somehow be put together? There are common threads between the different requirements. Rather than having two policies for treatment plans, couldn’t your organization take the verbiage that both CARF and the County or payor need and combine them into one?


Most organizations look at this work and decide to put it off. Until they need it and it’s way too late. But if you do a little at a time, just work on one section a week, it can make a difference. It’s like when your child or teen’s room is very messy and tell them to clean their room. They look at you and wave their hand (or worse) and don’t do anything. But if you work with them doing one part of the room today, another part the next day, it doesn’t end up a huge chore. 


What’s in your manual? Is it information you and your staff need? The adage is: if you haven’t read it in a year, and no external agency needs it, toss it. It’s not necessary and no one will miss it. When you’re ready to educate your staff about the manual’s contents, they will be happier to use it if it’s informative, helps them do their job, and avoid making mistakes. 


Praxes provides consulting on policy and procedures as part of its consulting services. For more information, please contact us.



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