All policies, guidelines and procedures should be
outcomes-focused and based on the best available evidence at the time.
Keep all policies and procedures in a manual accessible to all practice
members. This manual should be available both in a printed version, and
ideally as a digital version in PDF format easily accessible by all staff on
site (note that even in paperless offices there should still be a printed
version on site).
All practice members should be required to
read the manual and familiarise themselves with the content and layout. This
should be an integral part of the induction process. All staff should sign and
date a form to testify they have read it. Any future amendments should be read
and signed by all staff. As an alternative, team meeting minutes where all
staff are present and agree to policy can be counted as documentary
“Policy and procedure” should be a standing item on
the agenda of every practice meeting, allowing for a new policy to be
discussed or an existing policy to be examined.
members should be set a small section of the manual to read (the most
important sections is ideal) as part of early induction, to be followed up by
management as a discussion to determine their comprehension of these and
highlight the importance of the manual to all staff at the practice.
When staff ask a question they should be directed to the manual
to find the answer.
When formulating policies and
procedures, seek input from all practice members.
Coordination of policies/guidelines development and review should be
the responsibility of a dedicated person allocated to the role (e.g.
Coordination of the typing,
distribution and archiving of the policies/guidelines should be the
responsibility of the policy/guideline coordinator.
that the manual includes a history of the practice, identifies standards and
goals, describes operation and states the rules and regulations. It must be
user-friendly, up to date, relevant, accurate and accessible to all practice
A manual should contain all the information needed
to perform all practice duties. In theory a new untrained staff member should
be able to use the manual to work in the practice unassisted. It should be a
living document that is constantly changing to accommodate new
All requests for new policies/guidelines or
revision of existing policies/guidelines should be forwarded to the
policy/guideline coordinator via the policy request form:
request for existing policies/guidelines should be met within one week,
- Requests for new policies/guidelines or
modification of existing policies/guidelines should be considered in
consultation with the author of that policy/guideline.
- Where new
policies/guidelines are required outside of the scheduled review process, they
should be written in consultation with the relevant author, and reviewed by
at least one other relevant staff member.
- The person requesting the
policy/guideline should also be informed of the outcome of their request
within one week.
A standardised format should
be used when writing policies/guidelines:
- Font specification
should be Arial or Century Gothic Size 11 to allow easy reading. Format should
follow the standard practice template.
- Each section of the
policy/guideline manual should be a stand-alone document allowing for easier
review/additions and distribution of updated policies/guidelines by section,
rather than the whole manual, if required.
- Use diagrams wherever
suitable to help make the manual user friendly and easy to read.
- Each section should be sequentially numbered.
- To control reviews
and updates, the date of development and version should be noted in the
References should be based on the best
available evidence at the time and include international, national and state
governing and professional bodies’ legislation, regulations and guidelines.
In addition, any leading published research, best practice, etc. should also
Wherever possible, references should be no more
than five years old, unless they are seminal work or the current version. In
this instance, they should be no more than ten years old.
references should be stored/documented in a reference library, including
source, availability and location.
All references should be
stored/documented in a reference library, including source, availability and
Practices participating in the accreditation process
will be required to substantiate their policies and procedures as part of
accreditation which is carried out every three years.
policies/guidelines should only be distributed in hard copy or PDF ‘read
only’ files wherever possible, to protect the original version.
A formal process should be available to allow feedback and input from
the users, such as sign-off when they receive and approve of the
policies/guidelines, a feedback form in the policy/guidelines manual to
communicate any suggestions for improvement, and an annual satisfaction
For medico-legal reasons policies/guidelines should
be kept for at least seven years. An archiving system should be coordinated
by the policy/guideline coordinator.