There is little doubt that it can be challenging to manage policies and procedures in a way that makes your organization better, more compliant, and more efficient. In many cases, there may be thousands of regulations to wade through and possibly thousands of documents to review, especially in a large hospital. Of course, the goal when setting up an automated policy management system is always to make the process easier. That is why we have2 listed some basic concepts to keep in mind, in order to keep you on track to doing just that.


All organizational policies and procedures must always be accessible to all personnel in the organization. That means knowing exactly where documents are stored and archived. The old way, in which documents are kept in binders or stored on shared network drives, is over. With an automated policy management system, the best location for your policies and procedures may very well be your intranet or other web-based document management system. By doing that, you can provide advanced searchability and keyword tagging, making it easier for staff to locate the right policies and procedures when they need them.

To make all of this work, think hard about how the policy documents are organized and published. It’s always a good idea to look at organization from the perspective of the staff, since they will be looking for and using the documents most. You may decide a single document belongs in multiple folders, but a better idea is to place the document in one location and link to it directly from the other locations. Uploading multiple versions of the same document in different locations can lead to confusion and create problems when it comes time for review or an audit. Imagine how difficult it would be to update a document and make sure you got all 15 copies. Only having to correct one version of a document will reduce the instances of human error.


A critical element of ensuring that policies and procedures are always up to date is the ability to identify the ownership of each document. It is necessary that each document have a specific author, approver, and moderator. That moderator should have oversight of the review and update process.

Be sure your authors are following the standards put in place for review by assigning review dates to policies. Moderators should have a process for ensuring that authors and owners keep documents updated, whether you just use a basic spreadsheet to keep track, or you go into an automated policies and procedures management system. Also, since staff is always turning over, document ownership can change over time, so have a plan in place to account for that.


For such a system to work for everyone, make sure all documents look much the same. To achieve this, store all documents is a standard, electronic format. If you transition to an electronic system from a paper system, re-type all documents from the paper copies, and ensure they’re all in the same format. Since most people are familiar with Microsoft Word, that may be an excellent choice.

In addition to the file type, use the same physical template for every policy document, including the same style, the same logo and the same naming conventions for every document. Decide on specific keywords, and stress consistency in tagging to enable easier searches. By making sure all policies and procedures have a certain level of uniformity, you will make everyone more comfortable when using the system.