The importance of policies and procedures

Every organization has them. Every organization needs them. But how many place policies and procedures among their overall goals? That’s what’s happening this
year for Hallmark Health System. The board of trustees has identified compliance with policies and procedures as an organization-wide goal for 2015. Having and adhering to up-to-date policies and procedures also is mandated by many government agencies and outside organizations, such as the Joint Commission.

Last summer, the federal Occupational Safety and Health Administration cited one Hallmark Health hospital for a violation of a potential employee safety hazard.

“One of the areas cited was in relation to our written policies. Had the policies and procedures related to the OSHA complaint been current, this issue never may have risen to this level,”said Tessa Lucey, MHA, CHC, CHPC, corporate compliance officer. “We take employee and patient safety very seriously and have resolved these particular issues.”


There are more than 50 manuals and 4,000 documents within Policy Manager, the Hallmark Health online policy and procedure manual. For example, all the activities described in this issue – codes, incident reporting, and weather emergencies – have policies and procedures detailed in Policy Manager. Updating this resource is one part of the overall initiative.

There are two main parts to the process: reviewing each written policy and making sure that staff know about it and put it into practice. A third element is ensuring that the practice and policy match. “Sometimes, new clinical best practices can overtake the old written policy,” said Lucey. “This is why it’s so critical that policies are updated and revisited at least every three years.”

Despite the volume of work involved, the process has some benefits for employee and patient safety. “For one thing, it makes us think about all our processes,” said Lucey. “Also, it can identify areas for improvement so they can be fixed before an issue arises.” She added that “policies need to be lived, not just read in a manual. Our ultimate goal is that they are so ingrained that they just become the way we do things.” 

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Hallmark Health System, in partnership with The Massachusetts Department of Public Health, The...


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