Policy, Procedure and Guideline Development

Overview of Issue

Ensuring clarity in healthcare organizational policies, procedures, and guidelines (PPGs) will enhance compliance and reduce liability. Evolving case law suggests that staff impacted by a PPG should be i) aware of the PPG and ii) comply with the PPG (with some exceptions). During legal proceedings, involved staff will be evaluated against their normal practice, existing regulatory standards and related organization PPGs in place at the time of the event. For these reasons, in the event of litigation, plaintiff’s counsel will scrutinize these documents to determine deviance in staff’s action(s) and what the PPG outlined. Careful attention to language and setting attainable standards expectations is advised. Reduce liability by ensuring that the organization’s PPG development process includes a plan for informing, educating and training on the PPG.

Key Points

  • Careful attention to language, education and training, and storage of these key documents will reduce liability in the event of a lawsuit.

Things to Consider

Managing Liability

  • Following a patient/client/resident harm event, identify and sequester a copy of all relevant PPGs for the time period in question and retain until the case is closed (e.g. actions of the practitioner may be held to the PPG in place at the time of the incident).

Policies and Policy Management Systems

  • Adopt a standardized template for all administrative and clinical PPGs, including definitions for policy statement and procedure.
  • Monitor and execute organizational communication, training, education and implementation plan obligations.

Policy Development

  • Define the policy statement (what we do) and the procedure (how we do it) instead of relying on the “knowledge, skill and judgment” wording.
  • Consider the implications associated with developing a ‘standard’ versus a PPG (e.g. may be considered a binding admission of what the standard of care may be, not reasonable/feasible and/or enforceable and may conflict with regulatory body standards/ expectations).
  • Use simple, clear, concise language and avoid unnecessary technical terms.
  • Avoid: gender references, abbreviations and acronyms, superlatives (e.g. using words such as “the best”), repeating regulatory body standards verbatim, lengthy PPGs (more is not best), negative tone, and passive voice.
  • Use: “guideline” or “procedure” (provides more flexibility and allows for clinical judgment), “may” or “consider” (provides a guideline to follow but allows for clinical judgment as necessary), “recommended” for recommended actions, “acceptable care”, and “must” for mandatory actions.

Archiving and Retention

  • Include the effective date, past review date and revision date on all PPGs.
  • Retain expired/out-of-date administrative and clinical PPGs for a period required by the organization’s retention requirements

Policy Review

Pre-Development and Development

  • Check references (e.g. Medline) and conduct an evidence search to support current professional, regulatory and national standards.
  • Adopt a standardized PPG approval process.
  • Format documents to ensure staff can quickly find pertinent information and instructions.
  • Use position titles, not individual names.
  • Avoid using telephone or pager numbers as these can change frequently. • Ensure consistency with college standards.

Implementation, Compliance and Maintenance

  • Avoid confusion; have one system for staff to access documents (electronic or paper).
  • Develop a communication and implementation plan when drafting the PPG and consider training or educational requirements; use a variety of adult learning principles and educational models, information, communication and training methods and audits as required ensure awareness and compliance.
  • For emergency preparedness procedures, have a print copy or other means to access documents.
  • Adopt best practices for reviewing and updating clinical PPGs; track compliance with the review/revision schedule.
  • Where available online, include a disclaimer on each PPG that reads something like: “The Intranet (or the healthcare organization’s specific source) is the most recent version of this policy”.
  • Ensure the active and archived system is backed up regularly.


  • Canadian Medical Protection Association. (2016). Medical-legal handbook for physicians in Canada.
  • Dearmon V. (2013). Risk management and legal issues. In L. Roussell,(Ed.) R. Swansburg & R. Swansburg (6th Ed.), Management and leadership for nurse administrators.
  • Latin v. Hospital for Sick Children, (2007) CanLII 34 (ON S.C.).
  • Ontario Hospital Association. (2013). Records retention toolkit - guide to the maintenance and disposal of hospital records.
  • Pepper J. (2013). Policy and procedure development and management [Webinar]. HIROC.