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How to Write Hospital Policies & Procedures

by Michele Vrouvas, Demand Media

    Like corporations, hospitals conform to industry-wide standards of governance. They draft mission statements to clarify their goals and empower directors to enforce those goals. Without a dedicated staff, hospitals cannot carry out their goals and provide optimum services. Like corporations, hospitals can inspire employee loyalty through policies and procedures that apply to all. Assembling these policies in one manual makes them easily accessible and promotes compliance.

    Step 1

    Make a cover page that includes the title of the policy manual, the hospital's name, the date policies were issued and the office that prepared them. Write a table of contents as the next page. It should coincide with the policies and procedures written in Step 2.

    Step 2

    Make an index that arranges policies and procedures in alphabetical order by subject. Write each policy and procedure in a separately titled subsection.

    Step 3

    Design an "Update Record Form" with column headings for "Date," "Revised by" and "Policy." Explain that changes to policies must be dated and signed by the person who revised them. Provide rows of lines beneath column headings for recording policy changes.

    Step 4

    Write an introduction that explains the purpose of the policies and procedures. An example might be: "The policies and procedures collected in this manual are intended to help department heads supervise their teams and inspire staff to fulfill the hospital's mission." Identify personnel who drafted the policies. State that the policies are subject to change by designated staff, such as the hospital's administration or board of directors.

    Step 5

    Insert a page of "Definitions." Define the terms "policies" and "procedures." Emphasize the difference between them. For example, policies stem from the hospital's goals, while procedures serve as strategies for achieving goals.

    Step 6

    Add a flowchart or graphic that demonstrates the policy development process. Discuss roles that top-level supervisors and department managers play in initiating, developing, interpreting and enforcing the guidelines.

    Step 7

    Provide a contact page. Identify hospital administrators who can answer questions about the policies. For example, the planning and analysis staff might be contacted about hospital-wide policies, while human resources might be asked for information about personnel procedures.

    Step 8

    Include a page entitled, "Distribution of Signed Policies." Identify hospital supervisors who signed off on policies as part of the approval process.

    Step 9

    Conclude the policies and procedures manual with a statement explaining how they are to be used. Specify that employees should interpret the policies on the basis of consultations with the appropriate department heads.

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    About the Author

    Michele Vrouvas has been writing professionally since 2007. In addition to articles for online publications, she is a litigation paralegal and has been a reporter for several local newspapers. A former teacher, Vrouvas also worked as a professional cook for five years. She holds a Bachelor of Arts in history from Caldwell College.

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