Guide to Developing an Organisational Policy & Procedures Manual

This outline has been designed to assist community organisations to organise and develop written polices and procedures manuals.

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What are Policies & Procedures?

Policies and procedures are not the same. They have different purposes and are at different levels of detail. A Policy is a statement that clearly and unambiguously sets out an organisations guiding principles and views about a particular matter. It is a set of principles that provide a definite direction for the organisation. Policies assist in defining the intended aim of the organisation. A Procedure/Practice is a clear step-by-step method for implementing an organisations policy or responsibility. Procedures describe in detail a logical sequence of activities or processes that are to be followed to complete a task or function in a correct and consistent manner. Procedures can be described in the form of: written steps of the process flowcharts checklists A Protocol/Clinical Guideline supports clinical decision-making by describing best practice, evidence based and standardised treatment options developed through an examination of evidence and agreement among practitioners. A protocol is usually tied to a clinical policy and often clinical protocols are kept in separate manuals to the organisational policies and procedures. Note: For most policies a procedure that supports the policy will need to be created but a policy is an overview and is not required for every action or issue. For example, a separate No Smoking policy is not necessary when an organisation has the no smoking statement in their Workplace Safety Policy as well as in their employment and induction processes.

Why have Policy?

So people working in an organisation can have a framework for actions that help them get on with the job they need to do. So people in the organisation dont have to keep on discussing the same issues every time they arise one well thought out decision can be applied to many similar cases for efficiency. Reduces the organisational risk through mandating compliance. So legal and other requirements can be met and as a quality improvement tool.

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Why have a Policy & Procedures Manual?

A Policy & Procedures Manual is a written record. It should be readily available to all people involved in the management or work of an organisation. The Manual should be kept electronically and as a loose-leaf file for people to easily refer to. A Master Copy folder of all policies and procedures should be kept as a record and updated as polices and practices are reviewed and amended. Unwritten polices and procedures often lead to confusion and conflict.

To have separate or combined policy and procedure manuals.

Some organisations separate their policies from procedures and have two manuals. Other organisations combine them into not only a single manual but also a single document. There are pros and cons for using either system - a single manual can become overly large and cumbersome but two manuals can potentially be harder to keep aligned. If the organisation has a single focus or limited range of activities/teams a single combined manual may work well. If the organisation has a range of services and sites multiple separate manuals may be needed. If multiple manuals are kept then administrative procedures that are shared throughout the organisation, for example, applications for annual or study leave, these should be in each manual. Organisations can choose the system that best meets their needs as long as there is a specific document control system to keep the manual updated.

Steps in writing policies

In community organisations there are processes that are commonly used for developing policy: 1. A policy/planning/evaluation day (or weekend) 2. A consultative process for developing particular policies 3. A policy review process. In addition there may be formal processes such as a Standing Policy & Procedures Committee who develop and review policy recommendations and decisions.

1.

Planning/Evaluation Day

The stakeholders in the organisation come together for a day and develop key organisation policies such as: Mission Organisational Philosophy Aims, objectives, strategies Determining priorities for policy development

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Tips: Involve all the stakeholders; get a facilitator, especially if there are known value differences between those participating; use lots of butchers paper to keep track of the content of the day; and have a good time.

2.

Consultative Policy Development Process

Consultation provides the opportunity to: Eliminate problems such as duplication, ambiguity and inconsistency Verify or clarify complex information or issues Identify potential barriers to successful implementation Obtain other perspectives and viewpoints, including raising organisation or external issues Seek new ideas and expertise Promote good relations between sites and services providers and encourage participation and a feeling of ownership in the process Test out new proposals and ideas. Once the policy or procedure is in draft form an electronic copy should be placed on the organisation server or intranet to enable wide reaching consultation and to allow for general comments. Consultative Process: a. Collectively identify an area for policy development b. Staff or another group, brainstorm the issues involved (Tip: focus on naming the issues; dont necessarily attempt to resolve the issues) c. Write a first draft d. Distribute the draft and consult across the organisation for comment e. There may be a meeting to review all the feedback, written and verbal and to amend and revise the draft (Tip: again, where there are major differences of view, name them, dont try to resolve them) f. Re-circulate the draft and continue this process as necessary g. Write a final draft h. Forward the final draft to the Board/Management Committee to endorse i. Document the date the policy was ratified on the policy and the review date j. Incorporate the new policy into the Policy and Procedures Manual k. Communicate the new policy to all the relevant people and if necessary, a date is set for a training/information session to ensure all staff have the knowledge and skills to implement the policy.

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3.

Policy Review Process

At a staff meeting or Board/Management Committee meeting once every 12 months look at the organisational manual and ask whether the policies in it are still relevant and appropriate. If not, a process like the one above would be followed to revise existing policy or develop new policy Tip: In small organisations wanting to develop an organisational manual, consider the following: Devote time at a staff meeting at least once a month to brainstorm issues related to one area of policy Review the draft of a policy that has been prepared as a result of previous brainstorming At every Board/Management Committee meeting, devote some time to reviewing a draft policy and making decisions on it.

What could the table of contents look like?

The following is an example table of contents of an organisations policies and procedures manual. Introduction: This section can outline the purpose of the manual and the intended users Section 1: Service Management A. Overview of the Program/Service 1. History of the service/program 2. Mission 3. Aims, goals & objectives 4. Philosophy 5. Service Code of Practice 6. Outcomes B. Standards, Rights & Responsibilities 1. Service Standards 2. Organisation Code of Conduct 3. Organisation Rights & Responsibilities 4. Volunteer Rights & Responsibilities 5. Staff rights & Responsibilities 6. Advisory Committee Rights & Responsibilities 7. Policy on Conflict of Interest C. Incorporation 1. Copy of the constitution 2. Copy of the Associations Incorporation Act 3. Information on the requirements of the Incorporation 4. A copy of the register of Member Organisations 5. A copy of the register of Management Committee Members 6. Annual General Meeting requirements and copies of forms such as: Application for membership, Notice of AGM, Nominations of Officers
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D. Board/Management Committee 1. Committee responsibilities: legal responsibilities policy & planning financial staff other committee responsibilities 2. Roles and responsibilities of Board/Management Committee Members: Chairperson Secretary Treasurer Other Management Committee Members 3. 4. 5. 6. Orientation Kit for new Board/Committee Members Terms of Agreement for Board/Committee Members Code of Behaviour for Management Committee members Agenda format for Board/Management Committee Meetings: Time Attendance

Agenda Quorum Role of Manager at Management Committee Meetings Template for Meeting Minutes
E. Organisational Structures 1. Organisational Chart/Diagram 2. Accountability Chart 3. Organisation Meetings and Processes F. Planning and Evaluation 1. Evaluation Policy & Plan 2. Evaluation Strategies 3. Ongoing monitoring 4. Presentation of data 5. Consumer feedback 6. Stakeholder feedback 7. Planning day agenda 8. Forms: Data Collection Sheets, Data Reporting Format, Client/consumer questionnaires, Community group questionnaires G. Insurance 1. Policy regarding Insurance 2. Insurance and Indemnity policies: Students, Volunteers, Personal, Accident, Public Liability, Professional Indemnity, Directors & Officers, (Management Committee), Organisation vehicles, Volunteer vehicles, 3. Register of Insurance Policies detailing all current Insurance Policies H. Assets Management 1. The Asset Register
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I. Funding Agreements 1. Summary of current funding sources 2. Copies of current funding agreements are optional but details of accountability requirements for each funding source (including reporting requirements) should be included 3. Polices and Procedures on applying for grants/funds 4. Policy & Procedure on Fundraising

J. Financial Management
1. 2. 3. 4. 5. 6. 7.

Role of the committee and Treasurer Principles of Financial Management Financial Report Formats Project Budget Sheet Project Reconciliation Sheet Financial information Recording and Reporting timeframes Categories of Receipts and Payments

K. Use of Equipment & Vehicles

1. Policy on use of Private Vehicles 2. Policy on use of Organisation Vehicles 3. Policy on Depreciation 4. Register of Motor Vehicles 5. Motor Vehicle Log Sheet 6. Motor Vehicle Accident Procedures 7. Policy on Traffic Infringements incurred during service delivery 8. Policy on Transporting clients in vehicles 9. Procedure for Transporting clients in vehicles 10. Motor Vehicle Breakdown Procedures 11. Motor Vehicle Maintenance

L. Occupational Health, Safety & Welfare

1. Policy on Health & Safety Workplace Health & Safety Act 1995 and Amendments 2. OHS site inspection checklist 3. Workplace accident procedures 4. Accident Reporting Form 5. OHS Incident Register Injury/Insurance Record 6. OHS Communication Procedure 7. Workplace Smoking Control Policy 8. Employee Safety Awareness Questionnaire 9. Manual Handling Procedures 10. Workplace Health & Safety Representative 11. Fire Control and Evacuation Procedure 12. Health & Safety Training on the causes and prevention of work related illnesses and injuries: Furniture & Equipment, Visual Display Units and Eye Strain, Stress, First Aid 13. Safety and security procedures on home visits 14. Workers Compensation and Return to Work

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M. Service Delivery 1. Promotion of services: Brochure on the organisation and its services 2. Consumer Information: Client Handbook 3. Prioritising Requests for Assistance 4. Client Intake and Assessment: eligibility for service informing the client: if service is refused if the client is placed on a waiting list Clients With Special Needs: Aboriginal and Torres Strait Islander Clients Non-English Speaking Clients Clients who cannot read or write Clients with disabilities physical/intellectual 5. Assessment Forms and principles to be observed in Assessments 6. Privacy & Confidentiality in the Assessment Process 7. Privacy & Confidentiality of Information 8. Records length of time records are held 9. Identification 10. Clients Rights & Responsibilities 11. Dealing with suspected carer/care recipient abuse 12. Suitability checks/Police checks for service delivery staff 13. Client Reviews: Client Complaints Procedure Clients Record Form Dispute Resolution Process between clients and staff Confidentiality of Complaints Service Delivery completion/Exit 14. Referral: Referral consent Privacy & Confidentiality Client Care Plans and Coordination with other services Care Plan Reviews Care Plan protocols 15. Fees: Capacity to pay, Payment of fees, Scale of fees, Services for which fees are not charged, Collection of fees, Appeals mechanism 16. Safety Precautions in Service Delivery: Back Care, Infection Control Procedures

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Section 2: Human Resources

N. Staff Recruitment 1. Policy & Processes for recruitment of staff 2. Equal Employment Opportunity/Workplace Harassment Policies 3. Anti-Discrimination Laws: Federal Racial discrimination Act 1975 Federal Sex Discrimination Act 1984 Federal Disability Discrimination Act 1992 Relevant State legislation 4. Recruitment processes: advertisements, short-listing, interview panels, standard interview questions, interview scoring 5. Suitability checks/police checks for employees 6. Procedure for starting a new member of staff 7. Appointments & Contracts 8. Staff Personnel File 9. Staff Orientation Kit O. Role Outlines & Conditions of Employment 1. Employment Agreement 2. Code of Conduct 3. Confidentiality Agreement 4. Taxation forms, superannuation, payroll information/forms P. Staff Management & Development 1. Staff reporting Procedures and Formats 2. Staff travel 3. Staff Work at home 4. Timesheets 5. Record of Annual Leave 6. Policy on Staff Supervision and Performance Development 7. Policy on Training and Development of Staff 8. Team meetings 9. Performance Appraisals 10. Staff Performance Dispute and Grievance Procedure 11. Employee Exit Procedures and Exit Interview Record Q. Volunteers 1. Policy regarding why have volunteer involvement in the organisation 2. Volunteer Code of Conduct 3. Role Descriptions for identified volunteer positions 4. Initial Contact/Volunteer Application Forms 5. Reference/Police Checks 6. Volunteer Personnel Record 7. Induction 8. Volunteer Training Policy and Process 9. Rights and Responsibilities of Volunteers 10. Confidentiality Agreement 11. Performance Review 12. Volunteer Awards and acknowledgement 13. Reimbursement of expenses 14. Use of Motor Vehicles
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15. 16. 17. 18.

Occupational Health & Safety Dispute/Grievance Resolution Polices and Procedures Staff disputes with volunteers Misconduct/Volunteer Dismissal

R. Administration and Office Procedures General Organisation: opening hours attendance absences and punctuality dress code computer software platforms, authorised and unauthorised copying, back ups, use of external drives representing the organisation office resources & using office equipment personal phone calls gifts and soliciting office security maintenance.

Writing a Policy
Policies are part of the organisational approach to an issue and are a signpost to the way the organisation conducts its decision-making and actions. Therefore the document itself and the control systems should reflect a commitment to quality. Each policy should follow a standard format for consistency. It is also important that information about the date the policy was developed and its authorisation as well as the date for review is included. There is no particular right or wrong format for a policy as long as the above information and the page numbers indicate a sequence that is, written as: page 1 of 5 so that it can be easily seen if any part of the policy is missing. Some organisations like to have the document information on a cover page, others at the start or ending of the document. Some organisations also include the name of the primary or lead author others do not.

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Examples of a policy format: Example 1: Status Authorised by Initial Approval Governance Policy Final Executive Committee May 2010 Review Date Responsibility Version May 2011 Chairperson 1.0

POLICY 1. This Governance Policy was developed to guide the Executive Committee of Wonderland Society Incorporated in carrying out its activities. 2. All management team members and Executive Committee members of Wonderland Society Incorporated are expected to be familiar with this policy. The Chairperson will be responsible for, and hold the Master Copy of this manual. 3. The Chairperson is responsible for ensuring that the organisation adheres to the policies in this manual. Any abuse or neglect of these policies must be dealt with in the normal disciplinary process and must be reported to the Chairperson straight away. Scope: 4. All Executive Committee members and management. Definitions Term Executive Committee Meaning The governing authority of Wonderland comprising members of the Society appointed according to the Constitution.

Purpose: The Executive Committee will adopt as its guiding principle a governing rather than managing approach to its stewardship; it will make every effort to separate the roles of governance and management and maintain a focus on strategic or long-term issues and those associated with ends rather than on day-to-day administration and operations. The Executive Committee will: Utilise its Code of Conduct as the base document from which it takes its operational direction. Be familiar with and adhere to the Constitutional rules in the Constitution. Keep its focus on the strategic implications and required outcomes of programmes and services rather than on their management

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Maintain an emphasis on the policy implications of all matters coming before it. Accept the principle that the Executive Committee speaks with one voice, that no one member shall publicly express his/her own opinion should this deviate from an agreed Executive Committee position or decision. Accept that the Executive Committee is accountable to its consumers, donors and the general community for the organisations actions and decisions.

Provide formal induction training for new members and provide ongoing training to ensure positive support for members in their work on the Executive Committee. Note: This policy would continue on to detail the election of members, specific roles and responsibilities and duties of the Committee, conflict of interest declarations, meetings and so on.

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Example 2: March 2011 Version 1 1. Rationale

Quality Policy ABC Incorporated ABC Inc Quality Policy 1 Exec 1.3 Page 13 of 19

ABC recognises the importance of developing a learning environment where continuous quality improvement (CQI) is seen as essential for organisational development. The improvement process for ABC includes ongoing assessment of information from meetings, feedback, surveys, audits, member assessment and reviews. ABC also recognises that the Staff Meeting is a key mechanism for identifying improvements and feeding back on the impacts of improvements. Through combining quality issues into the staff meeting everyone has an opportunity to drive the continuous improvement system. This policy includes reference to the ABC Complaints Policy and Processes. 2. Desired Outcomes of Policy All staff, Executive members and members are aware of the policy and the processes they use to engage in a CQI framework and environment. A culture of CQI exists within ABC so that staff, Board members and clients feel confident that the organisation will embrace change as a positive aspect of development.

3. Policy ABC will endeavour to demonstrate its commitment to CQI through: 3.1 ongoing evaluation of feedback from staff, Board and members, program participants, and other stakeholders; 3.2 monitoring how we work which includes conducting reviews and surveys to assess the effectiveness and efficiency of individual and organisational performance; 3.3 collection and review of accident and incident data from staff and visitors, audits and review of hazards and maintenance issues to make sure our environment is safe; 3.4 encouraging open communication and respecting individual differences in order to work as an effective learning organisation;

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3.5 maintaining clear and sufficient documents to provide accurate, timely, honest and balanced reporting and decision making; 3.6 striving to make the best use of resources and property and to provide good value for money 3.7 seeking to act in an ethical manner that is consistent with the values and philosophy of the organisation. Guidelines (i) Members, program participants and staff are encouraged to complete evaluation forms to provide feedback on service delivery, safety and risks to themselves and the organisation. These include:

A general feedback form for both positive and negative feedback for all stakeholders A Complaints Record Form for the lodging of complaints against the service or staff An Event Report for describing accidents or incidents that affect visitors to the service or that impact on external peer reviewers A Staff Accident/Incident Report for describing accidents or incidents that affect staff of the service A Hazard Report for describing areas of risk or requiring maintenance to ensure staff and client safety

An original copy of these forms is stored in the Quality Policy Manual. All forms are also available electronically and are located on the W drive of the shared network. The Coordinator maintains an up-to-date Improvement Register that details all of the issues raised on improvement. In this way the ABC will monitor issues and improvements. At the end of each month the Coordinator is to prepare a Monthly Data Report for the Management Committee.

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Sample: Combined Complaints Policy and Procedure Policy No: Policy: COMPLAINTS Date Effective

COMPLAINTS POLICY
Review Date:

Complaints Policy
Rationale: The AMS Community Service recognises the importance of having a policy and set of procedures relating to any complaints that are made against it or against people working for it. Purpose: To have a fair policy and set of procedures for situations where complaints cannot be resolved between the parties themselves. Procedures: These procedures are to be worked through step by step. At the completion of each step, if both parties are satisfied, the procedures can be ended. If parties are not satisfied, continue to the next step. At any point of intervention, all parties have the right to have their supervisors and/or advocate and/or family support present. The complaint will remain confidential to the parties involved. This grievance procedure will be exercised in a way that will ensure any person/organisation complaining has the opportunity to be heard and treated fairly. Step 1. Approach the person/organisation directly about the problem, gain any relevant additional information and create a complaint record. Step 2. If not satisfied: Give a written description of the grievance to the chairperson of the ABC Community Centres committee. The chairperson will notify the person/organisation making the complaint that the complaint has been received. This written grievance is a private document and will be seen only by the committee, the independent mediator and the person/organisation the complaint is directed at. Step 3. The CEO/Manager/Board will read and discuss the complaint within one week.

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Step 4. The person/organisation complained about will be notified of the complaint and will be given an opportunity to read the written complaint and respond. If the complaint is unable to be resolved at this stage, it will move to Step 5. Step 5. An independent mediator will be engaged to enable both the person/organisation making the complaint and the person/organisation the complaint is against, to be heard. The complainant will be given two dates to choose from, and the meeting will take place within two weeks. Step 6. If mediation is not successful, the CEO/Manager and two members of the Board/Management Committee, including the chairperson, will meet with both parties together with an independent mediator as facilitator. From this meeting a final decision will be made and any action directed to take place. This meeting will happen within two weeks of the previous meeting. Step 7. The CEO/Manager will report the decision to the Board/Committee, the person/organisation making the complaint and the person/organisation complained against within one week of the previous meeting. Step 8. Enter a record of the complaint into the Complaints Register.

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Writing a procedure Procedures are clear details about what needs to be done, how it is to be done and by whom to implement a policy or follow legislation, for example, how to lift safely. A procedure may also contain diagrams such as flow charts or photographs of equipment. As with policies it is best to use a standard format for all procedures. To write the procedure use plain and simple language and step-by-step sub-headings to make sure all the details are easy to see and to follow. Give some thought to whether the information is best presented in words, charts or diagrams. Structure the procedure so that the purpose and scope is stated up front along with details of those individuals/groups to whom it applies and any exclusions or exceptions. List each step of the procedure in the actual order in which it is to be done. List any documents or forms that are to be used with the procedure and either include or attach examples of these. With procedures it is a good idea to trial them - ask someone not involved in their development to follow the steps. Identify any gaps or problems and redraft the procedure using the information gained. Have the procedure authorised and inform/train staff.

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Sample Procedure Format

Name of Procedure

1.

Purpose of the procedure

Describe the objective and purpose of this procedure what is to be achieved and why. Detail the responsibility for undertaking this procedure who does this relate to and how. List any policy that this procedure specifically relates to. 2. Special Considerations or Exclusions

Skills and expertise are there any specific skills and expertise required to perform this task? Safety issues are there any safety issues to be aware of while undertaking this task? Are their any circumstances in which this procedure does not apply or should not be used? 3. Procedure steps

List the details of each step in the procedure 3.1 3.2 3.3 3.4 [key activity] [key activity] [key activity] [key activity]

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Some risks or pitfalls with policies can be: If policies are developed just to meet the requirements of funding or accreditation bodies they can be out of line with the organisational philosophies and values or actual work practices. In this situation of policy to please others policies from other organisations are often used. This is fine provided that these policies are given adequate consideration about whether they are the right fit and content and are altered to suit. Similarly, policies that are developed purely by management or purchased from external consultants may not accurately reflect the reality of how things are done and staff either are unaware of the policies or do not follow them. Any of these situations can be counterproductive for the organisation if staff are unable to demonstrate either knowledge of the policies or that they refer to the policies in their work. Maintaining the Manual It is important to ensure that the manual stays up-to-date that it has good documented version control and that staff are made aware of the latest versions. Even though most staff should have contributed to developing the policies and procedures, all version control should be through one designated position. In this way, the manual can be accurately maintained and controlled. As previously mentioned, the template should include the date ratified and the version number, for example [V1], with subsequent versions [V2], [V3] etcetera]. Reviewing policies is equally important so that policies dont get out of step with new or amended legislation, clinical best practice or other changes to work processes. Loose-leaf folders with single sided copies are recommended for manuals so that changes can be made to individual documents without having to change the whole document. An amendment sheet should be kept at the front of each policy and procedure manual, and each time changes are made, a new sheet inserted. In addition, a sign off form can be very helpful and useful to record that staff have read a policy or procedure, and to record any comments. This is also useful as evidence to external reviewers of staff involvement in the writing, revising and revising knowledge of policies and procedures.

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