Policy

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.

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.

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.

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.

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.

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.

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:

• Posted on OP3.

Basic Policy Hierarchy

The different policy instruments available to us at Nova Scotia Health exist in a hierarchy with each other:

1. Legislation is at the top, as we're all required to follow the law and can't write policies that contravene the law.
2. Policy and clinical protocols are mandatory to follow, so they come at the top of the hierarchy for our organization's documents.
3. Procedures are steps that are required to be followed, often informed by the direction set in policy.
4. Guidelines are recommendations that aren't binding.
5. Other supporting documents, which are often linked to policy as related documents, can be used to support the direction set in policy.
6. 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: