Posted on December 6, 2022

By Angela Rapp Kennedy, CQL Vice President of Training and Learning Initiatives

CQL staff routinely receive requests for sample policies and other resources to assist organizations to develop, implement, and maintain necessary policies. For organizations that have achieved CQL Accreditation, many Basic Assurances® (BA) plans include work directed toward the development and maintenance of best practice policies.

Since no two organizations are exactly alike in mission, vision, scope, and function, rather than providing sample policies, this Capstone is designed to share proven suggestions for organizations as they work through the process of creating essential, useful, and practical policies and procedures that are tailored specifically to their organization. The advice included here comes directly from CQL staff who review policies across hundreds of organizations each year. The areas addressed cover topics like development, structure, accessibility, practice, and updates and revisions.

Developing Your Policies

While most, if not everyone, reading this Capstone no doubt has policies and procedures in place, there is always a need for ongoing policy development. You will see the general message here is that there are many examples and resources out there to give you ideas about what you might want your polices to look like. Another general theme is to ensure that you are soliciting and paying attention to the voices of all your stakeholders. Your policies will be richer and more likely to be put into practice this way.

Policies are valuable in supporting the vision of your organization, not only to remain in compliance with a variety of entities. Consider policy development as an opportunity to improve the quality of life for not only the people you support, but the people you employ as well.

• Reach out to members of CQL’s Facebook E-Community to get ideas from other partners.
• Don’t “reinvent the wheel.” Collaborate and partner with other organizations to consider policies and procedures that have been proven to be effective.
• If you use another organization’s policy as your starting point make sure it fits with your organization’s operations and adjust accordingly (and change the name of the organization to yours!!!)
• Do not purchase policies. Save your money as there are plenty of examples and sources. Often those purchased policies don’t fit your organization and culture.
• Include people supported and staff from all levels of the organization in the creation (and revision) of policies.
• Once drafted, run policies by the people who are directly impacted by those policies – both people supported as well as DSPs and Front-Line Supervisors.
• Write one, delete two! More policies do not equal a better organization.
• Policies can be comprehensive while being concise.
• Have someone unfamiliar with the organization read draft policies to see if they make sense.
• Identify if something is required by state policy and where it is in that policy.
• If the policy is for regulatory compliance, hyperlink the regulation for reference.
• Just because your state allows something, (think restrictions) doesn’t mean your organization needs to allow it. If the state allows it but the organization does not , describe that clearly.
• If you need to put policies in an employee handbook, insert the exact policy. You should not re-write, re-phrase or summarize the policy.
• Only address “what ifs” that could reasonably occur. Don’t “what if” yourself into doing nothing or overreacting. In other words, you don’t need a policy for every untoward event that has ever occurred at your organization.
• Some (many) policies are necessary by law – some financial, HR, record keeping, etc. Make sure you have a solid understanding of the law with which you must comply. If not, don’t be afraid to ask for guidance from a professional or use a Google search – of course being sure to use only reliable sites.
• Use all the resources available to check your grammar and spelling.

Structuring Your Policies

Making the policy “manual” easy to navigate and understand greatly enhances the likelihood that the policies will be read and implemented. A “book on a shelf” – physical or electronic – that is never accessed serves no purpose and enhances no ones’ life.

• The policy structure/matrix should be easily navigable.
  • Policies and procedures should be grouped together according to topic/systems areas.
  • Do not use page numbers. Instead, use a numbering system based on systems areas. Example: Policy area 100: Rights Protection and Promotion. All of the policies within this area would be numbered 101, 102, 103, etc.
• The CQL Basic Assurances® provide a convenient structure to group your policies. Policy area 100: Rights, Policy area 500: Best Possible Health, etc.
• Do not repeat information in different areas – decide where it needs to go and put it there. Cross-reference if needed.
• Insert a Table of Contents into the beginning of the document, organized by section. Programs like Word offer tutorials on how to create a Table of Contents.
• If it’s an electronic file, that Table of Contents should be ‘clickable’ so that readers can quickly access the policy sections.
• If it’s an electronic file, include bookmark hyperlinks throughout to be able to move around the document with ease.

Ensuring Accessibility In Your Policy

The policy will only be useful if it can be understood. It is essential to explore all the ways you can create policies that speak to everyone affected by them. To achieve this, you need to include the people you support in the development of policies, as they can provide ideas and a sounding board regarding accessibility. You can also seek out advocacy organizations to provide ideas and input.

Here are just a few ideas for improving the accessibility of your policies:

• Make policies clear and concise by using simple, direct, and plain language.
• Create larger font size versions of your policies.
• Use available resources to check the reading level.
• Develop visual aids (graphics, pictorials, etc.) to support your written policy.
• Draft short, basic summaries of the policies.
• Produce videos, simple presentations, etc. to help communicate policies.

These are only a sampling of basic concepts relating to accessibility. The Self Advocacy Resource and Technical Assistance Center (SARTAC) has produced a number of resources that provide more detailed information about accessibility.

Putting Policies Into Practice

Explore a variety of options to ensure everyone in your organization knows and understands your policies. The only way policies can promote your vision, safeguard people, and improve quality of life, is if everyone is aware of them, knows where to find them, hears about them regularly, and is provided education and support to accurately and effectively implement them.

You should also consider publishing policies and procedures online so all stakeholders can have easy access to them, and to promote transparency. While many public institutions such as schools and hospitals publish these online, human services providers tend to keep their policies and procedures private.

• To turn policy into practice, you have to own the policy.
• Systems and practices should align.
• Policies aren’t just for regulatory compliance. They should guide other systems into meaningful practices.

Policy And Procedure Committee

You might consider assembling a policy and procedure committee that meets regularly. The committee could have a representative from the various areas of your organization. At least some of the members should be skilled in editing and have a knowledge of regulatory requirements.

Prior to meetings, you would share the policies with the committee members for input/suggested edits. During the meeting, the committee would then decide the final edits.

Updating And Revising Policies

No effective policy “manual” is stagnant. Life changes and policies should as well. If you have policies that have not been reviewed and/or changed in years, you may want to consider whether they are needed. Waiting and planning a review of all your policies at once can be a daunting, unpleasant task, that often gets put off. Instead, you could institute a schedule of consistently reviewing policies on an ongoing basis.

• If a policy and procedure isn’t working, figure out why and change it.
• Note the reason for the policy change (especially if due to a corrective action plan from a surveyor). This will help avoid wondering why the heck you have a certain item in your policy.
• Human Rights Committees are a great resource to provide a second look at policies to ensure that the content and language of an organization’s policies do not intentionally or inadvertently restrict people’s rights.
• There should be a schedule for reviewing policies, whether done through a standing committee or a separate team that is convened. The review should consider if the policies still make sense and incorporate any changes that are needed.

From Compliance To Improving Quality

When you view policies beyond the lens of compliance, you are setting the stage for them to support the mission and vision of your organization. They can truly be a vehicle to protect and enhance the lives of people supported and guide the important work of those employed by an agency. Embracing this perspective, will change the way you write and maintain policies.