Drafting Policies

Submitted by troy.murphy@up… on Wed, 12/06/2023 - 13:14

In this section you will learn to:

Identify and use policy formats and structures in drafting policy initiatives.
Draft policies that reflect and are appropriate to the organizational context.
Draft and present guidance and resources to support policies and their implementation.
Facilitate consultation on draft policy initiatives to identify implementation issues.
Modify draft initiatives to address implementation issues.

Supplementary materials relevant to this section:

Reading G: A Guide to Plain English
Reading H: Diversity and Inclusion Policy

We now turn our attention to the actual writing of the draft policy initiative. Here, you take the ideas and priorities you have identified through your self-assessment and existing policy review, research, and consultation and create a document or set of documents that clearly set out the new policy direction and the steps that will be taken to achieve it. This will then be used for the testing phase, which is discussed in the final section of your module.

Sub Topics

Core to developing your policy initiative will be writing up policy documents, including policy statements, procedures that guide staff in enacting policies, and resources that remind or encourage staff to thoroughly follow these policies. Before we get started exploring templates and formats for organisational policies, let’s remind ourselves of why we develop them:

Workplace policies often reinforce and clarify standard operating procedure in a workplace. Well written policies help employers manage staff more effectively by clearly defining acceptable and unacceptable behaviour in the workplace, and set out the implications of not complying with those policies.

A workplace policy consists of a statement of purpose and one or more broad guidelines on action to be taken to achieve that purpose. The statement of purpose should be written in simple terms, free of jargon. The length of the policy may vary depending on the issue it addresses.

A policy may allow discretion in its implementation and the basis of that discretion should be stated as part of the policy. A policy may also be required where there is a diversity of interests and preferences, which could result in vague and conflicting objectives among those who are directly involved.

^{(NSW Government, n.d.)}

To meet these aims, you need to develop policies that are comprehensive and clearly communicated. As you work through the examples in the pages that follows, consider how well they meet the standards outlined by this NGO policy consultancy firm:

Policy contents

Organisational policies will vary depending on topic matter and purpose, but should be comprehensive, and should generally contain the following sections:

Rationale or purpose statement: Reason for issuing the policy and the desired effect or outcome.
Scope or coverage statement: State who is covered and affected by the policy, and who may be exempt.
Date: State when the policy comes into force.
Definitions: Include clear and unambiguous definitions for terms and concepts in the document.
Responsibilities: State who is responsible for carrying out individual policy statements.
Policy statement/s: Specific regulations, requirements or modifications to organisational behaviour.
Procedures: Policies and procedures may be separate documents, however if you are drafting an operational policy, it should detail set procedures to be followed.
Date of review: Specify date set for review and frequency of reviews.

Organisational policy development: key considerations

Best practice approaches to developing and implementing policies include:

Accessibility: Ensuring policies are made widely available and in accessible formats.
Clarity: Ensuring policies are written in a clear, concise manner using plain English.
Accountability: Policies and procedures should set out who is accountable for implementing the procedures, and also accountability for updating/maintaining the currency of the policy.

^{(BNG NGO Services Online, 2022)}

Using policy formats and structures

We generally start with a policy statement (you might remember that this is the technical meaning of ‘policy’, although the term is generally used to refer to other documents such as procedures). What should be in a policy statement? It should include a clear statement about the commitment of the organisation (e.g., to provide a safe workplace) and, if relevant, how this links to the organisation’s philosophy (e.g., promoting and facilitating wellbeing). Some organisations use relatively brief policy statements, such as this example from Business Victoria’s recruitment policy template:

Recruitment Policy

Policy

{Business Name} recognises a robust and professional approach to recruitment and selection helps us to attract and appoint individuals with the necessary skills and attributes to fulfil our aims and support our business goals.

All appointments should be made on the Principle of Merit, compliance with all relevant Federal and State Legislation and adherence to this policy and related processes.

Our business recruits people via the following methods:

Internal
External
Employee Referred

^{(2019, p. 23)}

This clearly doesn’t meet the criteria for comprehensiveness set out above. Let’s look at another example, the format for which breaks up aspects of the policy:

My Health Record System Policy

1. Background and rationale

To govern the use of the My Health Record system, the My Health Record system Rule states that in order to participate in the My Health Record system, your organisation needs a written policy in place to address access and security issues relating to the use of the system.

2. Purpose

To ensure our practice conforms with the requirements of the My Health Record Act by addressing each of the requirements specified therein.

3. Scope of Policy

The policy extends to all AHPRA registered healthcare practitioners working within the practice and administrative staff who have responsibility for maintaining user access to the My Health Record System on behalf of the practice.

4. Description

All healthcare practitioners within the practice actively use My Health Record system to access and upload patient health information as required in the provision of healthcare. Examples of health information that can be accessed and uploaded are allergies, current medications, investigation reports, diagnosis and patient health summaries.

^{(Allied Health Professions Australia [AHPA], 2019, p. 10)}

Other formats are more detailed, such as the example in your next reading.

Reading G

This reading is the suggested workplace discrimination and harassment policy suggested by the Australian Human Rights Commissions (AHRC) and guiding information. Note the definitions and details provided, such as links to legislation, to help staff gain a thorough understanding of the issues the policy is designed to address.

The key things that need to be included in your policy statement, whatever format/template your practice uses, are (1) clear details about who the policy applies to and, among these, who has specific responsibilities described in the policy’s procedures and (2) sufficient information about the policy that readers understand why following the policy matters. In particular, adding a definitions section to provide clarity on key terms used in the policy and links to relevant resources can be invaluable. It is most common these days to include all relevant procedures in the same document as the policy. These follow immediately after the end of the policy statement, including its definitions, rights, responsibilities, and so on. These need to clearly delineate each relevant procedure (often numbered) and include the actions required to enact the policy. Let’s return to AHPA’s My Health Record System Policy for an example (note that it starts at 5, because 1-4 are included in the policy statement).

1. Practice procedure
5.1 Managing user accounts:

An up to date register is maintained, including the names and positions of staff who are authorised to access the My Health Record system
Healthcare provider software controls ensure access to the My Health Record system is limited to those staff whose duties require them to access the system. Any person involved in an individual's healthcare who is authorised by the healthcare organisation can access a My Health Record.
Each staff member is provided with a unique user account with individual login details and these details should not be shared with others.
Staff passwords are regularly reviewed, changed and sufficiently complex i.e. a combination of more than 13 letters, numbers and symbols
Users are required to deactivate screensavers by entering their username and password or other suitable method of user authentication.
A user account is immediately suspended or deactivated when a user leaves the organisation, has the security of their account compromised or whose duties no longer require them to access the My Health Record system
A user account is inactivated/deleted after the departure of the staff member as part of the organisation's off-boarding process
Where access to the My Health Record National Provider Portal access is required, the organisation maintains a list of up-to-date authorised providers and communicates this with the Australian Digital Health Agency (the System Operator).

5.2 Identification of staff:

Clinical software is used to assign and record unique internal staff member identification codes, including a Healthcare Provider Identifier-Individual (HPI-I), when applicable.
The unique identification code, or the provider's HPI-I, is recorded by the clinical software for each instance of My Health Record system access.
HPOS / PRODA is used to maintain a list of HPI-I numbers for each current staff member requiring access to My Health Record.

5.3 Staff training:

All staff requiring My Health Record system access undergo training before accessing the system.
Training is provided and outlines how to use the My Health Record system accurately and responsibly, the legal obligations for organisation and individuals using the system, and the consequences of breaching these obligations.
Training is provided to staff on a regular and ongoing basis to ensure changes are communicated and understood by all practice team members
A register of staff who have attended training is maintained.
Staff that are not eligible to access the My Health Record understand their obligations in relation to privacy and security of patient information.

5.4 Destroying My Health Record document codes:

Staff provided with My Health Record security codes (by their patients) to access restricted records and documents within the My Health Record system must not record these within the clinical desktop software system or in any other electronic format.
If codes are recorded on paper, these documents must be destroyed immediately following the consultation / when no longer required by placing them in locked containers that are removed and shredded.

5.5 Handling of privacy breaches and complaints:

The organisation has a reporting procedure to allow staff to inform management regarding any suspected security or privacy issues or breaches of the My Health Record system.
An incident register/log is kept of any suspected breaches, including details of the date and time of the breach, the user account that was involved and which patient's information was accessed, if known.
A process is in place for the Responsible Officer (RO) or Organisation Maintenance Officer (OMO) to report a breach to the System Operator (the Australian Digital Health Agency).
If a patient raises an issue in relation to unauthorised access to their My Health Record, the organisation has a complaints management process to take steps to investigate the issue.

5.6 Risk assessments:

The organisation undertakes periodic privacy and security risk assessments of staff use of the My Health Record system and the organisation's ICT systems generally, and implements improvements as required.
All risk assessments are documented appropriately.

^{(2019, pp. 10-12)}

Procedures are the details of the tasks that need to be undertaken in order for the policy to be upheld, including regular ways of doing things and actions only to be undertaken in specific circumstances. Where some procedures need detailed instructions in order to be carried out effectively, these are generally provided in protocols, checklists, informational posters, or flowcharts, that are provided to all relevant personnel and which should be included in appendices to the policy. Examples include WHS checklists, payroll process flowcharts, and posters showing proper handwashing technique.

Case Study

As she prepares to draft the new secure messaging policy, Monia searches for existing policies or templates and finds one provided by AHPA. It’s background and purpose seem to align with the aims of introducing secure messaging in her practice, and the scope and description are similarly aligned with her intentions for her new policy:

1. Background and rationale

Secure electronic messaging significantly lessens the chance of clinical information being accessed and read by anyone other than the nominated addressee. While electronic transmission carries an inherent risk of inadvertent wider broadcast of information, it also offers the opportunity to protect information more efficiently through higher security standards, encryption, audit trails and point to point transmission of data.

2. Purpose

To ensure that our practice utilises standards-compliant secure messaging systems that have the capability to both securely send and transmit clinical messages to and from other healthcare providers. (p. 8)

3. Scope of policy

All messages sent and received that contain clinical information. All health practitioners working within the practice or their nominated representative.

4. Description

Secure Messaging Delivery System – [Insert name of secure messaging software]

All healthcare practitioners within the practice actively use secure messaging (within the clinical software where available) to send, receive and act upon patient clinical documentation/information. Examples of clinical information are referrals to other practitioners, allied health and specialists. (2019, p. 8)

When Monia reviews the procedure, however, she realises that the policy she develops will need to have significantly more information that the template provides:

5. Practice procedure

Our practice:

sends and receives correspondence and reports to and from our clinical desktop system to other healthcare providers through the use of conformant secure messaging software
supports all healthcare providers in our practice to actively use secure messaging software to send and receive patient documentation, where feasible
adheres to the use of compliant software to ensure that message contents are encrypted for the entire transmission process using appropriate digital certificates
has verified that the installed software for secure messaging delivery has been configured in accordance with commissioning requirements
does not support or condone the use of insecure electronic methods of transmission for communications containing identifiable clinical information (e.g. standard email)
encourages a sustained increase in the use of standards-compliant secure messaging systems
where possible uses a National Authentication Service for Health (NASH) Public Key Infrastructure (PKI) organisation certificate to facilitate sending and receipt of documents.
provides practice-based education and skills-based training to all healthcare providers and staff to ensure compliance with the policy and competency in the use of the technology

6. Related resources

Secure messaging | Australian Digital Health Agency

My Health Record conformant clinical software products | Australian Digital Health Agency (Adapted from AHPA, 2019, pp. 8-9)

Many of her staff, for example, will not know what some of the terms mean. She also considers the need for the responsibilities of particular roles, including her own, in making sure that the policy is adhered to and providing the necessary resources. Monia decides that she will add a ‘Definitions’ section and expand the basic procedure so cover:

The general responsibilities of workers and managers at the practice.
The specific responsibilities of management, including ensuring the appropriate processes in installing and updating the secure messaging system and oversight of its use.
A procedure for the senior member of every team to monitor the use of communications systems and compliance with the policy, including identifying and meeting staff training needs.
A procedure for client-related communication with a practitioner or organisation not using a compatible secure messaging system.

Self-Reflection

Think about the different types of policies you will need to develop as a practice manager.

What are the essential points that you think are required regardless of the format used?

Have you seen one or two formats that you think are particularly effective? What do you like about them?

Do you think the same kind of format and level of detail will be needed for all of them?

Drafting a New or Updated Policy

Writing Clearly

We now turn our attention to the practicalities of writing effective policy documents. As we do this, keep in mind the purposes of your policy initiatives: We develop policies and procedures so that the people working in our practice have clear information about what their responsibilities are and have the guidance that they need to meet these responsibilities. This doesn’t mean that every action a manager or staff member takes must be spelled out in policy, but that core principles and activities of the business are clearly described, and guidance is provided for meeting legal and ethical responsibilities, as well as working in accordance with organisational expectations, values, and purposes. This means that we need our policy documents to be very clear and accurate. (Unfortunately, some policy documents and certainly many of the resources that we use when researching policy initiatives can be very complex in their language.) Wherever possible, we want to make the policy documents that we create simple and easy to navigate by those who need to use them. As you develop policy documents and many other documents within your practice, you will find it very useful to employ the principles of plain language.

Reading H

This reading gives you an introduction to, and simple steps for starting to develop plain language resources. These principles are not only excellent for your internal organisational communication but will help you develop resources and communications with external stakeholders, such as clients and community members. Plain language documents are easily understandable by most adults and many younger people. There may still be situations in which you need to have documents translated or adapted, or to work with interpreters, so that people who are unable to thoroughly comprehend the documents themselves are supported in doing this. You can find more guidance on writing accessible, inclusive documents in the Australian Government’s Style Manual.

Alignment with Organisational Principles and Culture

It is also important that the policy documents you create are consistent with the philosophy, purpose, values, and day-to-day practices of your organisation. (We have already mentioned the idea of a practice philosophy in one of the examples we gave earlier.) As an allied health practice, your practice philosophy will probably relate to values or concepts such as promoting well-being, enabling people to function more affectively, enhancing healthy longevity, or other health-related principles. (Note that this is an organisational philosophy, not the type of limited philosophy for a particular policy that we discussed earlier.)

Self-Reflection

Find several examples of healthcare practice philosophies online. What themes do they share? How do you think these might influence the behaviour of staff (including managers)? How might they influence the development of policies relating to service provision, human resources, and staff behaviour?

Your organisation may also have a set of values (commitments to important principles). Common organisational values include integrity, honesty, and providing quality services. Both practice philosophy and values will probably be closely linked to the practice purpose or objectives. As an allied health practice manager, it is likely that your organisation has stated purposes relating to providing a service that enhances health among the groups you serve.

If the philosophy, values, and purpose of your organisation are genuinely held – that is to say, they are not simply nice ideas that management likes to promote but principles that guide organisational and management practices – this will influence the organisational culture in positive ways. For example, an organisation that has respect as a central value and operates in alignment with this will communicate to at staff on a daily basis that they are valued. The staff are then likely to feel more comfortable and confident in their roles, that they are part of a larger team with a shared purpose, and that their own and their teammates’ value is recognised. This then promotes positive interactions between and among staff members and managers, positive interpersonal behaviour with clients, and a responsible approach to work in general.

Organisational Culture

Organisational culture is the outcome of many factors, forces and influences. Key elements and attributes of culture are:

individual values: Individual values are the ideas, actions and relationships that an individual holds to be of most importance. They are a significant influence on the way an individual interprets, responds to and acts within the workplace.
organisational values: The roles, functions and aims of an organisation determine what, collectively, needs to be valued most in order for the organisation to succeed. These are commonly expressed through corporate documents such as strategies, annual reports or press releases. […]
alignment between personal values and organisational values: A functional culture is fostered when staff perceive that there is some alignment, connection or ‘line of sight’ between their individual values and what needs to be valued for the organisation to succeed.
dynamism: An individual’s values can shift and be re-ordered. Equally, what needs to be valued within an organisation can change in response to a range of internal and external influences. Thus the collective alignment of individual and organisational values— organisational culture—is fluid and subject to change.
the role of leaders: Leaders in organisations influence culture by acting as role models for the behaviours and actions that align with what the organisation needs to value the most. Leaders also help staff to identify a connection between personal values and organisational values. […]

^{(State of Victoria, 2013, p. 18)}

It is possible for organisations with positive cultures to nonetheless have some differences in those cultures. For example, an organisation with values, either stated or implied, relating to the demonstration of professionalism may have this value reflected in the more businesslike or clinical appearances and behaviours of staff, while an organisation with a more casual culture may still provide a very positive and professional service but with a less professional manner of dress or speech considered normal within the organisation. Neither organisation has a better or worse culture, necessarily – if both are respectful and facilitate a high quality of service delivery and treatment of others, they are both positive cultures.

Where an organisation has an appropriate set of values and aims, and a positive culture, it is much easier to implement good-quality policies – those that are appropriate given the professional context, legal and ethical responsibilities, human rights, and so on. The relationship between these principles or workplace culture and the new policy initiative can be part of the rationale for the initiative and making this clear to stakeholder provides them with a sense of the importance of taking the policy initiative seriously. A worker who has a commitment to supporting healthy functioning and alleviating suffering, for example, will naturally be inclined to take seriously a policy initiative that they know has a role to play in achieving this aim.

Questions to Consider when Assessing Organisational Culture

When considering the following questions:

look for disparity between ‘stated’ individual and organisational values versus ‘revealed’ values; do the stated values correspond to what you actually see? For example, when staff (or leaders) claim to value collaboration and cooperation, do you actually see insularity and disconnection?
don’t just go to your ‘go-to’ people. The high profile, vocal and visible employees within an organisation may provide useful insight into the prevailing organisational culture, but won’t necessarily tell you about subcultures or countercultures.
look out for the ‘poor cousins’ of the organisation; are there groups (formal divisions, particular disciplines, or a social grouping) whose contributions are perceived as less valuable than those of others?
What do you hear staff say when they discuss work, clients, other divisions, or their managers?
What do leaders say when they discuss work, clients, other divisions in the organisation, or their staff?
What do staff and leaders talk freely and enthusiastically about?
Are there ‘elephants in the room’? What do people avoid discussing?
Are there ‘sacred cows’? What principles, processes or people do staff take steps to defend?
What makes staff and leaders upset or angry?
What sayings, slogans or mottos are repeated throughout the organisation?
How do staff celebrate individual and organisational milestones?
Who attends social events?
Who interacts with whom at social events?
What stories do you hear?
Who tells the stories?
What is the message or moral of the stories?
How are those with different views treated?
Is debate welcomed, or are divergent views ignored or shut out?
How do staff and leaders behave in response to ad hoc requests, especially those that are unusual or require extra effort?
What makes staff (including leaders and managers) stressed or anxious? For example, demanding deadlines, unfavourable media attention or external scrutiny).
What appears to matter more?
rules or relationships?
the individual or a group?
self-control or self-expression?
achievement or approval?
creativity or compliance?
convention or inventiveness?
avoidance of conflict, resolution of conflict, triumph over others?
What do managers pay the most attention to?
Do they focus on problems and crises?
Do they also acknowledge successes?
How are decisions made?
by one person, by consensus, or not at all?
What kinds of behaviours get rewarded?
getting along with colleagues, getting things done, something else?
What kinds of behaviour are frowned upon or condemned?
How is poor behaviour dealt with? Is it ignored or tolerated, or is it reprimanded?
If the organisation were a person, how would you describe it?

^{(State of Victoria, 2013, p. 18)}

Naturally, you want your policy documents to both reflect and encourage a positive culture, where appropriate values, philosophies, and objectives are shared and where they drive effective service delivery. Policies that do not reflect or encourage a positive culture and behaviour in alignment with values, philosophies and objectives have some serious problems. Policies that act counter to established patterns of behaviour or work practice among managers and staff are unlikely to be excepted or followed and may create stress and confusion among the managers and staff instructed to follow them. This can make policy development within an organisation where there is a poor culture, or where only lip-service is paid to appropriate values and purposes, very difficult. A policy can be entirely appropriate, given the work setting and the legal and professional responsibilities the practice operates within, but will be very hard to implement within a poor culture.

This becomes more complicated because an organisation may claim to have a positive culture or a particular set of values and priorities when the culture is harmful, or the stated values and priorities are not acted upon. In these situations, more fundamental change, particularly among management, is needed to improve the culture and that is well beyond the scope of policy development. Nonetheless, you may like to take the opportunity to consider the organisation’s culture and whether there are policy initiatives or processes you could use to address aspects of organisational behaviour that are less than positive. For example, in a poor organisational culture, good human resources (HR) practices are likely to be omitted or undermined at times, but that is no excuse for having a poor set of human resources policies. If you are developing a HR policy in a context like this, the process is an opportunity to share information with staff and managers about the policy, as well as the legal, professional, and business principles that it is designed to uphold, then share resources or arrange training that may prompt those who have not been acting in accordance with good HR practice to improve. Similarly, if managers or staff are undertaking tasks using improper practices, is it not appropriate to develop procedures that describe these improper practices; you still need to develop procedures that outline appropriate practices but will also need to work with management and staff to guide a change in behaviour so that the proper practices are adopted.

Supporting Information

We have already looked at several types of documents that can help us effectively articulate the requirements of policies including policy statements, rationales, purposes, scopes, and procedures, as well as other forms of documentation or information may be important in supporting policy consultation and feedback, as well as implementation (flowcharts, posters, etc.). These should also be developed in accordance with plain language principles and, where appropriate, use images and other formatting options to engage your audience.

When we talk about supporting information policies, however, we are not limited to written documents. It may be useful to develop presentations for meetings, videos that can be shared with staff and manages, quizzes to test knowledge, or even activities and games to help those responsible for policy implementation to gain a comprehensive understanding of what their responsibilities are, and how to carry them out. It may also be useful to share information produced by others to support this understanding, such as sharing a publication that discusses an issue related to the policies, purpose, or an update to legislation that is relevant to the policy.

A group of medical professionals talking

Once you have a sense of what the policy initiative involves and have drafted the policy, including its associated procedures, you will need a plan for the testing, finalising, and implementation phases. This plan should include:

A clearly stated testing and feedback period. This includes ensuring that there is sufficient time for thorough testing of policy implementation and identification of any issues, as well as problem-solving regarding those issues prior to finalising the policy details.
The details of all stakeholders to be involved in this process – stakeholder mapping – including are you will involve them and how they can provide feedback to you.
Any resources that you need to acquire or develop to support the process and how you will acquire or develop them. This may include informational resources, but could also include physical resources, such as new clinical or administrative hardware; software, such as a new record-keeping or administrative programs; or training resources to up-skill people within the scope of the policy to carry out their responsibilities.
Methods for communicating throughout this process, including giving updates on testing and feedback, and the final outcomes, including ratified policies as they are released and go into effect.

It is a good idea to circulate the draft policy and supporting information before you test a new policy, because some issues can be identified simply by a stakeholder reading the policy. These issues can then be addressed before the draft is tested, which is obviously a simpler and less troublesome process than identifying issues during testing (where the policy is being carried out and such issues can cause service delivery problems, issues with administrative and financial processes, and so on).

This section of the module focuses on the vital elements to consider when drafting a policy document, including using policy formats and structures, and ensuring policies reflect organisational context. This section also covers implementation, including presenting guidance and support resources, and facilitating consultation to identify potential issues with implementation.

Allied Health Professions Australia. (2019). Digital health policy templates for allied health practices. https://ahpa.com.au/resources/digital-health-policy-templates/

BNG NGO Services Online. (2022). Policy development and implementation: Working towards best practice. https://www.ngoservicesonline.com.au/blog/policy-development-and-implementation-working-towards-best-practice/

Business Victoria. (2019). HR policy and procedure manual template. https://business.vic.gov.au/tools-and-templates/hr-policies-and-procedures-manual-template

NSW Government. (n.d.). Workplace policies and procedures checklist. https://www.industrialrelations.nsw.gov.au/employers/nsw-employer-best-practice/workplace-policies-and-procedures-checklist/

SkillSource. (2023). [Photo of folders that say ‘Policies’ and ‘Procedures’.] https://skillsourcelearning.com/drafting-remote-work-from-home-policies/

State Government Victoria. (2013). Organisational culture. https://vpsc.vic.gov.au/wp-content/uploads/2015/03/Organisational-Culture_Web.pdf

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M00521A

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