There are a number of policy instruments available to us at Nova Scotia Health, and each can be useful in different circumstances. Consider the policy instruments described here when thinking about your needs. If in doubt about which tool fits for your context, talk to the Policy Office.
Policy
Policy is the rule or the promise we are making as an organization. It is made up of clear, formal, and authoritative statements that:
- Direct organizational and clinical practice.
- Enable informed decision making.
- Prescribe limits.
- Broadly assign responsibilities/accountabilities.
- Are secondary or subject to relevant legislation, regulations, and bylaws.
Consider creating policy when:
- You need to set a high-level, clear standard about what must be done.
- You want to reduce unnecessary variability that may negatively affect patient outcomes or employee well-being.
- You're introducing significant changes in practice.
Policy should include:
- A clear purpose statement that describes what problem the policy is addressing.
- Principles and values that describe why the policy is important.
- Definitions.
- References.
Policy should not include:
- Education.
- Procedure statements (think "what," not "how").
- Information that will change frequently, such as brand names, specific contact information, etc.
- History or context about the issue.
Protocol
Protocol is a precise sequence of activities that define a specific management plan. It can include decision points, and is sometimes formatted as an algorithm or flowchart. It is usually based on practice guidelines or organizational consensus.
Consider creating protocol when:
- You need to develop a series of rules with decision points that need to be followed with little room for variation.
- You need to provide structured guidance for high-risk situations.
Protocol should include:
- A series of high-level steps that describe what must be done.
- Definitions.
- References.
Protocol should not include:
- Detailed explanations of how to carry out each step.
Procedure (or SOP)
Procedure is a set of steps or instructions that describes how to complete a task, enact a policy, or follow a standard. Standard Operating Procedure (SOP) is a type of procedure often used for technical professions.
Consider creating procedure when:
- You need to provide instruction on how to carry out the direction set in a policy.
- You need to assign responsibility for certain tasks or actions.
- You need to standardize how something is being done across the organization.
Procedure should include:
- Sequential steps.
- Enough detail so that team members know how to comply.
- Definitions.
Procedure should not include:
- So much detail that the steps become hard to follow across sites.
- Information that is facility or site specific, such as where to find a piece of equipment.
- Education.
Clinical Intervention Guide (CIG)
Clinical Intervention Guide provides the best option when a practical mix of direction and guidance is needed, enabling a health care provider to perform a clinical intervention, supported by clinical judgement.
Consider a Clinical Intervention Guide when:
- A mix of ‘must do’ requirements, inclusion criteria, critical information to inform clinical judgement, and ‘how to’ direction is needed.
- The focus is on the clinical intervention, not operational issues.
CIGs should include:
- Inclusion/exclusion criteria.
- Competency statements (if required).
- Critical information to inform clinical practice.
Other Supporting Documents
Other supporting documents can include things like manuals, forms, checklists, flowcharts, and algorithms.
Consider creating other supporting documents when:
- You need to support policy users in carrying out the direction set in your policy.
- You want to express your policy content in another way (e.g., a flowchart or algorithm).
- You have supporting information that changes frequently (e.g., equipment manuals or vendor lists).
Other supporting documents should:
- Be posted on departmental/program websites or intranet pages, forms databases, or other appropriate locations and linked as a related document in OP3.
- Help users comply with your policy.
Other supporting documents should not:
- Be placed in an appendix in the policy itself.
Local Work Instructions
Local work instructions are documents that provide specific instruction on how to comply with policy or follow procedure for specific roles, or at specific locations.
Consider creating local work instructions when:
- There are special considerations at your facility or site, or within your unit or team.
- You need to provide more detail about how to perform a task or use targeted language for a profession or role.
Local work instructions are:
- Written in a targeted way for your audience (jargon is okay here!).
- Specific and detailed.
- Posted somewhere that is accessible to the people who need them (e.g., bulletin boards, intranet).
Local work instructions are not:
Basic Policy Hierarchy
The different policy instruments available to us at Nova Scotia Health exist in a hierarchy with each other:
- Laws and Regulations are at the top, as we're all required to follow the law and can't write policies that contravene the law.
- Policy is a high level rule that must be followed without exception. Care Directives and Delegated Functions, as Authorizing Mechanisms, are considered Policy as well.
- Clinical Protocols and Clinical Intervention Guides have a mix of requirements and direction that guide the reader to perform as expected but may allow for moments of clinical/professional judgement to respond to more complex situations.
- Procedures are steps that are required to be followed, often informed by the direction set in policy.
- Clinical Practice Guidelines are high level recommendations based in evidence that are used to guide clinical judgement.
- Other supporting documents, which are often linked to policy as related documents, can be used to support the direction set in policy. This might include checklists, learning modules, and training manuals.
- Local business processes or work instructions are the best place ‘every day’ information needed for people to do their jobs.
Consider this hierarchy when thinking about which type of policy instrument or guidance document you need to support your work.
Risk vs. Frequency
You might also consider the frequency of the task in relation to the level of risk associated with it when considering what type of policy instrument is the best fit. Risk could mean the risk of harm to a patient, to a population, to equipment or property, to the environment, etc. depending on your context.
For example:
- If a task is routine and low risk, you may want local work instructions to support people in carrying it out.
- If a task is done infrequently and low risk, procedure might be an appropriate tool.
- If a task is routine and high risk, you may need policy and procedure to support it.
- If a task is done infrequently and high risk, you may need policy, protocol, and detailed procedure.
Consider the relationship between frequency and risk when thinking about what policy instruments might be appropriate, and talk to us in the Policy Office for help:
