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Developing an effective policy and procedure manual.

A well-written, comprehensive policy and procedure manual is the laboratory's single most effective management tool--and its most neglected one. With our budgets facing closer scrutiny, we need to delineate the lab's functions more explicitly. Yet many laboratory managers give low priority to developing a functional policy and procedure manual.

There are plenty of good excuses to avoid producing a comprehensive manual: too little time and too much work; uncertainty about the manual's contents or the difference between policy and procedure; unfamiliarity with the how-to of preparing the manual; or an unwillingness to put too much in writing. Underlying all these reasons is the failure to recognzie just how vital such a document really is.

This article will explain each step in preparing an effective manual. But first let's examine why your laboratory urgently needs one. Done the right way, written policies and procedures:

* promote teamwork and improve human relations.

* promote clarity, consistency, and continuity of performance and management decisions.

* establish approved, measurable standards of performance for competent practice.

* provide a tool for orientation and training of new employees and supervisors.

* help managers handle problems faster and with greater freedom by defining the parameters of their responsibility.

* promote proper delegation and define limits of authority and levels of responsibility.

* save supervisors time in answering questions and making decisions, and free them for planning and development.

* promote better employee understanding and retention.

* serve as a source document for inspection by regulatory and accrediting agencies.

* furnish a basis for orderly change, through additions, changes, or deletions.

To sum up, a good policy and procedure program clarifies management directives, reduces uncertainties, and saves time and energy. With these advantages in mind, we will define some key terms. The manual has five components: objectives (or purpose), policies, procedures, methods, and rules.

An objective is a broad purpose or aim. Objectives form the basis from which all policies are derived.

A policy shows how the organization will achieve its objectives. It is a guide to thinking and action, not a descriptive statement or a list of tasks. Policies are general statements covering all areas of the institution, although certain ones have a greater impact for some departments than others.

A procedure describes what is to be done--a detailed sequence of activities showing how a policy applies to a particular situation.

A method breaks down the procedure and tells how to accomplish it, one task at a time.

Rules establish procedures to govern or limit the activities outlined in the method. They also control conduct and indicate consequences if policies are not followed.

It's easy to understand these definitions when you translate them from theory into actual practice. Figure I shows a typical example of a laboratory's objective, policy, procedure, method, and rule. From a broad objective--providing optimum service--it narrows down to work schedules (method) and discipline for tardiness (rule).

Preparing a manual may seem overwhelming, especially if you're starting from scratch. A logical plan makes it much simpler. The following nine-step sequence is a basic outline of the process.

1. List topics for which the lab needs policies. What kinds of policies must you consider? There are originated policies, which come from top management as part of the institution's operational goals. Standard or routine policies reflect actual practices or systems established by precedent. Imposed policies, such as government regulations or legal requirements, originate outside the institution. Appealed policies arise from the department's need to cope with exceptional problems on a case-by-case basis.

2. Develop a table of contents to establish your topic areas. Figure II lists the major areas included in a typical lab policy manual.

These topics fall into three broad classifications: management, operational policies, and personnel policies. Most laboratories have little difficulty listing topics in the first two classifications, and Figure III lists some that should be included, from purchasing to public relations. The most common trouble spot is in the area of personnel. Since most institutions have their own comprehensive personnel policies and an employee handbook, it's easy to presume that nothing more need be said by the laboratory. But all labs have specific policies that their employees must know. These key points are listed in Figure IV.

3. Now draft the policies. This is the most tedious part of the job. Each institution has its own policy-writing format, like that shown in Figure I. Solicit input from department supervisors on their sections' concerns.

Remember that laboratory policies are general statements intended to channel employee decision making. They must be clear, comprehensive, flexible, and subject to revision; they must be fully understood by those who will apply them; and they should be written in simple, concise language. They cannot be changed by word of mouth. They should begin with the phrase, "It is the policy of Anywhere Memorial Hospital laboratory to . . . ." And they should reflect your institution's overall goals and objectives.

4. Review the draft to insure compliance with institutional philosophy, regulatory requirements, and compatibility with other department policies.

5. Circulate the draft policies to supervisors for review and feedback.

6. Draft appropriate procedures, methods, and rules for the policies, again with the participation of supervisors. When writing procedures, keep these points in mind:

Procedures tell what must be done to carry out policy, not how it must be done. The question of how is answered by the methods.

Procedures are more specific than policies.

They are written as a series of steps. (A method describes how to accomplish just one step.) Each step usually begins with an active verb in the present tense. Avoid negative statements.

7. Circulate drafts to supervisors for final comment.

8. Finalize policies and have them approved by appropriate administrative personnel.

9. Compile policies in a loose-leaf notebook to allow for revisions and additions. Introduce the manual to all laboratory staff in a series of meetings that explain its implications and use. Make it clear that all employees will be held accountable for reading the manual and complying with its contents.

Now that your policy manual is complete, don't think the job is over. The manual is a constantly evolving document that must reflect the changing reality of the lab. As new problems arise, precedents may be set or new policies may be identified. It's your responsibility to make prompt and accurate amendments.

Review all policies annually and update them as necessary. When a new policy is announced by laboratory memo or other directive, post the notice on the bulletin board and introduce it at a lab meeting. When changes are finalized, post them and insert them in the manual.

Getting started is the hardest part of developing a policy manual. Once you are past the hurdle of developing a table of contents and writing the first policy, it becomes far less formidable. And the work pays off, because the policy manual is the hub of all laboratory operations. It influences costs, productivity, efficiency, employee performance and morale, interdepartmental relations, and service delivery.

In other words, a solidly designed and well-written set of policies and procedures does more than make you look like an effective manager. It helps you become one.
COPYRIGHT 1985 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1985 Gale, Cengage Learning. All rights reserved.

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Title Annotation:management procedure manual
Author:Barros, Annamarie
Publication:Medical Laboratory Observer
Article Type:Bibliography
Date:Jun 1, 1985
Previous Article:Lab director issue pivotal in CAP's deemed status bid.
Next Article:The why of policies and procedures; an organization's purpose or mission gives rise to policies, and from policies flow procedures.

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