How to set up a policy and procedures manual

This three-part article describes the process followed by Northwestern General Hospital in establishing policy and procedures manuals. It also shares the discoveries made during this process which might benefit other hospitals attempting either to rewrite or create manuals of their own. Much of the available literature either deals with the need for policies and procedures, differentiates between policy and procedure, or gives sample policies or procedures for different hospital areas. These topics have been pointedly avoided here in favor of the practical aspects of policy and procedures manual development. The first part, 'Establishing the Basics", describes the brief and informal study of some existing hospital policy and procedure manuals and outlines the basic principles adopted as a result of this study. The second part, "Policy and Procedures Manual Preliminaries", reviews the considerations and decisions which were made by Northwestern General Hospital before work on policies and procedures could actually get underway. The third part, "Procedure Writing Skills", is more didactic and offers suggestions for improving the quality of procedure writing.