Keeping Policies and Procedures Current

Ted Markgren, CO(E), Senior Surveyor 

Your Policies and Procedures are at the core of your business efficiency and compliance. I encourage you not to think of the annual review of your Policies and Procedures Manual as a burden, but as an opportunity to make sure those policies and procedures still work for your business and employees. 

Granted, it does take some time and effort to review your policies and update or delete those that no longer apply or have changed. But, it’s definitely worth it in the long run. Keep in mind that your policy manual isn’t for the benefit of the surveyor, it’s the operations guide for your entire practice. Your policy manual informs and guides all employees as to your company rules, policies and expectations. Think of it like this; if your facility were a car, your staff the drivers and your patients the passengers, your Policy and Procedures Manual would be your ever-important GPS.  

If you’ve purchased your policy manual from one of the various sources for boilerplate policy manuals, don’t forget that it needs to be customized to reflect the activities of your business. For example, if you don’t offer rental equipment or have a delivery vehicle, there is no need for a policy or procedure for those items. Be sure to remove that extraneous material from the manual. All ABC surveyors evaluate your business practices based on what is included in your policy manual as much as by what we observe while on site. Policies that are outside the scope of your business are more harmful than helpful. 

Take time to actually read and update your policy manual. Assure yourself that all of your policies are applicable to your  practice and services. It’s always a good idea to include your staff in the review, they bring a different perspective and can help make sure you’ve covered everything. After all, your employees are the ones most often affected by the practice’s policies. 

We also encourage you to have an electronic copy of your manual. Not only is it easier to update and edit, but in the event that you’re unable to access your physical copy, an electronic copy would still be accessible.    

This simple activity can yield improvements to your practice’s policies, improve staff productivity and perhaps even uncover redundancies that can be eliminated. It’s a valuable use of your time with potentially great rewards.  

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