There are a number of policy instruments available to us at NSHA, 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.
Guidelines
Guidelines are a series of recommendations based on the best available evidence. They are not binding, and are not required to be followed.
Consider creating guidelines when:
- A single solution doesn't make sense, or for complex issues where there isn't a single agreed upon practice.
- You want or need to provide guidance on a topic, but can't or don't want to enforce compliance.
- You need to address an emergent issue, but there isn't enough information to make a firm decision or rule about how to handle it.
Guidelines should include:
- High-level guidance on potential courses of action.
- Information that applies to the majority of situations.
- Definitions.
- References.
Guidelines should not include:
- Steps that must be followed in every circumstance (this is more appropriate for procedure).
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 NSHA exist in a hierarchy with each other:
- Legislation is at the top, as we're all required to follow the law and can't write policies that contravene the law.
- Policy and clinical protocols are mandatory to follow, so they come at the top of the hierarchy for our organization's documents.
- Procedures are steps that are required to be followed, often informed by the direction set in policy.
- Guidelines are recommendations that aren't binding.
- Other supporting documents, which are often linked to policy as related documents, can be used to support the direction set in policy.
- Local business processes or work instructions are the best place to communicate facility or site-specific information.
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:
