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Policy & Procedure



What do we mean by Policy and Procedure (P&P)?

POLICY is a predetermined course of action or behavior established as a guide toward accepted business strategies and objectives. In other word, "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.


PROCEDURE  is a method by which a policy can be accomplished; it provides the instructions necessary to carry out a policy statement. In other word, 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.

P&P are necessary for both employees and the Department.  They ensure that employees know what is expected of them in any given circumstance, while at the same time protecting the organization from business interruption, shut down, needless lawsuits etc. Existing policies and procedures in various units need to be examined to determine three things: usefulness, redundancy, and where new policies and procedures are needed.

When writing P&P always use the following nine headings:


  1. Policy Statement (required)
  2. Reason for this Policy (required)
  3. Applicability of this Policy (required)
  4. Procedures (optional)
  5. Standards (optional)
  6. Guidelines (optional)
  7. Definitions (optional)
  8. Related Documents (optional)
  9. Revision History (required)

The optional fields may or may not be used in the policy and procedure document/manual but for consistency sake they are always included.  If one of the headings is not applicable to a particular policy simply write Not Applicable (NA) or N/A in that area.  Never delete a field.  This is necessary for consistency and clarity for the reader

Source: Summarized from 7 Steps to Better Written Policies and Procedures By Stephen B 


How to Develop Policy and Procedures

How To...5 Steps to Develop Policy and Procedure:

The following is a method of putting policy and procedure together for your manual. 

1) Identify issues


  • Review underlying concerns. Ask, "Do we have a policy about...?" Then, "Do we need a policy about...?"
  • Relate to philosophy, values, mission, goals. If it doesn't help further the mission and goals of your Agricultural Society then it may not be an appropriate issue for the organization.
  • Collect information that will help you draft the policy. Contact other Agricultural Societies or organizations in the community that have a similar situation.
  • Consult with people who will be affected. Get the big picture and remember good policy is based on fact, not opinion.
  • Describe desired outcome. What do you want this policy to do when implemented?
  • Outline alternatives that will give the desired outcome.
  • List positive and negative reactions that may occur. Look for weaknesses and limitations. Try to eliminate major gaps.
  • Choose the best alternative.

2) Draft policy

    • Make it as clear as possible. Use plain language, be brief and to the point.
    • Review with anyone it affects.
    • Be certain it is in agreement with by-laws.

        3) Approve policy


        • Directors approve policy at a regular meeting.
        • Record in the minutes.
        • Add to policy handbook.

        4) Implement

        • Communicate policy to all affected.
        • Put into action.

        5) Review and evaluate

      • Review regularly.
      • Does everyone understand the policy as written?
      • Is it working?
      • Adapt to meet changing situations.
      • 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.


        Department Policies & Procedures (DPP)

        Department Policies and procedures are a set of documents that describe an department's policies for operation and the procedures necessary to fulfill the policies. They are often initiated because of some external requirement, such as environmental compliance or other governmental regulations, these policies and procedure should reflect all department mission, vision and functions within the organization main mission.

        Policy and procedure writing often uses a standard format within an organization, including a complete history of changes made to the document. Typically, the format includes a purpose, persons affected, scope, sometimes a background section, a policy section, definitions, responsibilities, and a procedures section. The format when put into a template can also include information about the title, effective date, revision date, and an approval section.

        There are four very basic reasons that necessitate writing policies and procedures: Operational needs — Policies and procedures ensure that fundamental organizational processes are performed in a consistent way that meets the organization's needs.

        • Risk management —as a control activity needed to manage risk.
        • Continuous improvement — Procedures can improve processes by implementing a Plan-Do-Check-Act (PDCA) approach by building important internal communication practices.
        • Compliance — Well-defined and documented processes (i.e. procedures, training materials) along with records that demonstrate process capability can demonstrate an effective internal control system compliant with regulations and standards.

        A List of Proposed DPPs

        • General:

          • Statement of Purpose
          • Clinical Engineering Program
          • Areas of Responsibilities
          • Role of Clinical Engineering
          • General Definitions

        • Personnel:

          • Organizational Chart
          • Jobs Specifications
          • Employee Records
          • Staff List

        • Operations:

          • Medical Equipment Planning
          • Material Requisition
          • Incoming Inspection and Installation
          • Preventive Maintenance
          • Corrective Maintenance
          • Electrical Safety Testing
          • Emergency Service
          • Equipment Tagging
          • Equipment Procurement
          • Service Contracts

        • Quality Assurance and Safety:

          • Quality Assurance
          • Equipment Safety and Alerts
          • Infection Control and Safety Precautions
          • Safe use of Hands & Powered Operated Tools
          • Test Equipment Calibration
          • Emergency Disaster Plan
          • Non-Medical Equipment in Patient Care Vicinity
          • Quality Control for Renal Water Analysis
          • Environmental Rounds
          • Handling Hazardous Materials
          • Proper Handling of Medical Equipment
          • Safe Use of Lasers
          • Safe Work Practice

        • Training & Education:

          • Orientation of New CES Staff
          • Continuing Education
          • Training for Hospital Staff
          • Student Internship

        P&P Manual

        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.

        Your P&P manual will be unique to your pro-gram, but should contain the required minimum P&Ps that are common to all departments. 

        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.

        Click here for Office Policy Manual Reference Guide

        Reference Manuals

        One of the most important references required for clinical engineering department. CED should retain a copy (hard and/or soft) of the following manuals in the department for their work reference. These manuals are used as a guidelines for the department staff to be familiar and comply with them. The manuals would be developed by the clinical engineering department or another department in the organization, that would include but not limited to the following:

        • Safety General
        • Radiation Safety
        • Laser Safety
        • Laboratory Safety
        • Fire Safety
        • Infection Control
        • Material Safety Data Sheet
        • Preventive Maintenance Procedures
        • Administration Policy and Procedure
        • Employee Relation