Policies and Procedures Don't Equal Quality Improvement

Developing policies and procedures alone rarely leads to quality improvement. Attention must be given to issues in both their development and implementation.

The more written policies and procedures your hospital develops, the better the quality of healthcare it provides. Right?

Many organizations we come across have a notion that the troves of documents they call “policies and procedures” will somehow lead to quality improvement. Even worse, some organizations, especially their management teams, are convinced that their libraries of written policies and procedures symbolize success in improvement work.

These beliefs are false. They are false because hospitals that have written policies and procedures, without doing other necessary work for improvement, consistently lag behind their peers who have done more. In other words, the act of creating written documents (“policies and procedures”) alone is insufficient (though sometimes necessary) for sustainable improvement.

Are Written Policies and Procedures Necessary?

Our detractors will be quick to point out instances when written policies and procedures come in handy, even necessary.

As such, we shall make our position clear from the outset:

Written documents, in the form of policies and procedures, that set rules and guidelines in the performance of key care processes, when developed and implemented properly, may be useful tools for quality improvement.

For example, we expect policies and procedures for hand hygiene in any decent hospital. If these documents are developed according to evidence-based guidelines, with consultation of staff on the floor and other relevant personnel, and implemented appropriately, they have the potential to offer value. Therefore, we make the following points:

  1. Policies and procedures may be useful for quality improvement if developed and implemented properly;
  2. Policies and procedures alone should never be the main strategy for quality improvement (such a strategy is commonplace even today and it never works!); and
  3. Policies and procedures should be viewed as merely one of several facets in a comprehensive quality improvement plan, and not the plan.

Typical Scenario

Below is a brief description of the usual situation: An individual with a leadership role or a committee decides that a policy and procedure for a process (let’s call it “Process X”) is necessary. Someone, usually one with good language skills (i.e. he/she is a wordsmith) is asked to “draft” the policy and procedure. This person, more often than not, lacks experience, let alone expertise, in Process X. He/She does not receive (adequate) guidance from those familiar with Process X. This person proceeds to search for one or more documents on the topic, through the Internet and/or from other hospitals, with a view to “adopt and adapt” the document for their own organization. The “draft,” when completed, is then submitted to a person or persons (perhaps the Quality Council) with greater authority for “proof-reading”/”correction”/modification (which in reality is simply window dressing), followed by final approval (rubber stamping?) by leadership.

The document may be communicated to staff (some organizations don’t even bother communicating their policies and procedures). Staff are often oblivious to the content of the document. Even if they are aware of the content, they harbor resentment because (a) they were not consulted despite being the main users of the document, and/or (b) the content is not practical, leading to quiet improvisations and workarounds.

No changes are made to the document because no one involved in its development or approval is aware of the need for amendment and the guys on the floor are too afraid to speak up.

There may be slight variation between organizations but the description above is a close approximation of what happens in most places, regardless of geographic location—North America, Africa, South Asia, Southeast Asia, Australasia, it really doesn’t matter; we’ve seen a similar pattern of behavior throughout the world.

Why Policies and Procedures Don’t Lead to Desired Results

The reasons why policies and procedures fail to achieve their objective(s) can be broadly divided into:

  1. Problems with their development; and
  2. Problems with their implementation.

A. Problems with Development

  1. Unrealistic expectations
  2. Inadequate consideration when selecting policies and procedures
  3. Inadequate involvement of responsible persons when developing policies and procedures
  4. Excessive “adoption” or “adaptation,” and inadequate content expertise
  5. A static approach to development

1. Unrealistic expectations

Many organizations assume that whatever is written in their policies and procedures will be followed to the T. This is seldom the case. To the contrary, staff often do not follow what is stated in policies and procedures, despite multiple “reminders.” The staff may, or may not be justified in their apparent disregard for the policies and procedures, but simply expecting staff to follow what is written in the documents demonstrates a lack of understanding of how improvement is achieved and sustained in modern healthcare. Such a “top-down” approach is presumptuous for another reason—it assumes that the people who write those documents know the best way to execute the process. Without the involvement of staff on the floor, attempts at implementation are usually an exercise in futility. We suggest a contrarian approach that assumes a low baseline probability that written policies and procedures will be followed, and to work towards improving the chances of success by various means shown to be successful elsewhere, e.g.

  • Involving process owners in policy and procedure development
  • Testing on a small scale
  • Eliciting feedback from end users and acting on it
  • Defining how the effectiveness of the policy and procedure will be measured and at what intervals
  • Assigning a person or committee to be responsible for the implementation of the policy and procedure

2. Inadequate consideration when selecting policies and procedures

Some organizations try to maximize the number of policies and procedures they have on their shelves. Insufficient consideration is given to the likely utility by staff, return of investment (e.g. in terms of time and labor, opportunity cost), etc. One shortcoming of having more and more policies and procedures is the growing likelihood that they will be not be implemented. It is easier to develop and effectively implement, say, 100 policies and procedures, compared with, say, 1000. The best performing organizations that we work with attempt to minimize (not maximize) the number of their active policies and procedures by removing outdated ones or ones that are no longer applicable, and consolidating the rest. Streamlining the organization’s policies and procedures so that they serve end-users while still meeting accreditation and other regulatory requirements requires skill (far more than indiscriminately writing as many policies and procedures as possible) and significantly improves the chance of successful implementation.

3. Inadequate involvement of responsible persons when developing policies and procedures

Why organizations hire scribes (usually without sufficient relevant experience) to develop their policies and procedures continues to puzzle me. On the one hand, it may be more convenient and faster to have a dedicated “policy writer,” but this needs to be balanced against the utility of the end product, its acceptability by staff, and effectiveness in meeting predefined goals (if any). Lack of involvement by key individuals in the process leads to resentment and lack of buy-in, and the inevitable issues with implementation. We recommend that input is sought from all key personnel, with or without the use of a person to write the policy and procedure. This may take a considerably longer time than, say, an hour of Googling, but the results in the longer term are generally much better. This additional investment in time and effort will pay for itself.

4. Excessive “adoption” or “adaptation,” and inadequate content expertise

“Adopting/Adapting” another organization’s policy and procedure is common practice, presumably because it is easy to do and samples on almost any topic are readily available. While it may be acceptable, even advisable, to know what policies and procedures work in other organizations, it is incumbent upon the team to develop a policy and procedure that works for their own organization. This almost invariably means the active involvement of people familiar with the process, and a genuine desire to write an original document that will help to meet the organization’s goals, as opposed to churning out another window-dressed, but no less plagiarized, piece for the organization’s archive of policies and procedures.

5. A static approach to development

Many organizations write policies and procedures as if they were cast in stone; the documents will be written once, perfectly, and not be revised for at least the next few years (and sometimes forever). This mindset is problematic for a few reasons:

  1. The aim for perfection often means an unreasonably long development time because everything has to be “right” at the final draft. Sometimes, writing the document takes so long that it is never completed.
  2. Because the document is assumed to be “perfect,” no room is given for revisions, and therefore future improvements are unlikely.
  3. The emotional and political investment in the development process inevitably leads to an unwavering determination to see the document approved and unadulterated. “Too much meat in the game,” as we’d call it here in our consulting firm. This phenomenon is unhealthy because it obstructs improvement and breeds complacency.

Making policies and procedures work requires a dynamic approach, one that involves periodic reevaluation of relevance, practicality, and results.

B. Problems with Implementation

  1. Lack of communication and training
  2. Lack of feedback from end-users
  3. Lack of action in response to feedback from end-users
  4. Lack of a comprehensive approach to achieve the desired results

1. Lack of communication and training

Unless policies and procedures get communicated to the relevant staff and adequate training provided to them, all the time and effort put in development will count for nought. Unfortunately, however, much too often we see organizations having numerous policies and procedures but floor staff are oblivious to their existence.

2. Lack of feedback from end-users

As hinted above, it is necessary to elicit the feedback of those who will execute the policies and procedures, on a periodic basis, at least in the early stages, to discover any opportunities for improvement, e.g. incorrect terminology, ambiguous statements, constraints in the process, etc.

3. Lack of action in response to feedback from end-users

Even when feedback is provided, leaders often fail to follow-up on identified issues or suggestions for improvement, or fail to keep those who gave their feedback updated with the action plans. Even if it is determined that no further action would be taken immediately, for whatever reason, e.g. limited budget, leaders should communicate this to those who provided feedback.

4. Lack of a comprehensive approach to achieve the desired results

Despite a well-written document, proper communication and training, and responding to feedback, the desired results may still not be realized because things are done in a haphazard manner. A systematic, well-coordinated approach gives the organization the best chance of seeing policies and procedures living up to their potential. This is more likely if the implementation of the policy and procedure is overseen by an appointed individual or committee.


The development of policies and procedures consumes considerable resources, i.e. manpower, time, money. This activity should contribute to the organization’s mission and goals. Sadly, the mere presence of policies and procedures often fail to improve quality.

In this article, we discussed the common issues related to policies and procedures, which can be broadly divided into those associated with their development and those associated with their implementation. There are several ways that organizations can improve return on investment in policy and procedures.

When developing these documents, organizations should recalibrate their expectations, consolidate documents to better improve management of those in the active pool, involve staff knowledgeable in the process, consider what works for their organization (as opposed to rehashing documents designed for other places), and adopting a dynamic approach.

During implementation, we suggest leaders allocate enough resources for communication and training, elicit feedback, act on whatever feedback is received, and put in place a system that enables coordination, possibly by a responsible person or committee.

Need help with your organization's policies and procedures? Teh & Associates can train, guide, and support your staff to develop and implement policies and procedures that contribute to your organization's goals. Contact us today.