Policies and procedures are the workings of the
practice; they state your goals, the plan to achieve your goals and
any rules, as well as the modus operandi for the smooth running of
Set policies and procedures
Set policies and procedures promote continuity and a team spirit
as well as an atmosphere of good communication and support. A
comprehensive set of policies and procedures will assist in
resolving any disputes regarding performance and what tasks are
required to be completed. Ultimately, a good set of policies and
procedures may even assist in the resolution of an industrial
Policies and procedures are in writing so that all practice
members are aware of the overall direction and style of the
practice, how you do business, and the appropriate action to be
taken in a given situation.
See below for general suggestions, as well as a checklist for
the type of procedures to include in your practice manual. Avant has provided some
templates / sample texts for creating some (but not all) of your policies and
Improving your practice
- All policies, guidelines and procedures should be
outcomes-focused and based on the best available evidence at the
- 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).
- Encourage all practice members 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 evidence.
- '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.
- New staff 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
- Coordination of policies/guidelines development and review
should be the responsibility of a dedicated person allocated to the
role (e.g. policy/guidelines coordinator).
- Coordination of the typing, distribution and archiving of the
policies/guidelines should be the responsibility of the
- Ensure 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,
accurate and accessible to all practice members.
- 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 developments.
- 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:
- The request for existing policies/guidelines should be met
within one week, wherever possible.
- 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.
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- A standardised format should be used when writing
- Font specification should be Arial or Century Gothic Size 11 to
allow easy reading. Format should follow the standard practice
- 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 footer.
- 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 be included.
- 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.
- All references should be stored/documented in a reference
library, including source, availability and location.
- Policies/guidelines should undergo formal biennial review, or
sooner if any significant changes occur. Informal review should be
ongoing and commence from the time the manual is released. (The
NHMRC and ACHS recommend at least 3-5 yearly review or more often
where the subject matter is prone to rapid change.)
- Final policies/guidelines should only be distributed in hard
copy or PDF 'read only' files wherever possible, to protect the
- 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 survey.
- 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.