What Is PolicyAssist™?

  • Missing Key Policies?
  • Need Important Procedures & Protocols?
  • Wish You had Better Forms?


We Have your Solution!

PolicyAssist™ is a collection of policies, procedures, protocols, and forms developed over the years by QFHC and kept updated.  It is a dynamic resource with new documents and tools added regularly.  PolicyAssist™ also crosswalks documents to important regulatory and accrediting standards such as HRSA, NCQA PCMH, FTCA, AAAHC, and more.

And best of all...

PolicyAssist™ is included FREE with your subscription to the PolicyPLUS™ Document Management Module.

Policy writing and management is a critical administrative component of any health center.  These documents provide an accounting of governance, purpose, implementation expectations, and roles and responsibilities of key functions and processes.  In this white paper the following are explained as a guide to understanding the value of policies and policy management and steps to facilitate effective policy writing.

  • Why documentation is so important: Tips that could keep you out of trouble later
  • Who should write policies (qualifications of good policy writers)
  • What are the differences between policies and procedures
  • When to use handbooks, manuals, flowcharts vs. policies
  • How to achieve consistency using standardized policy attributes and format
  • How to organize policies (classifying and numbering)
  • When policies should be reviewed and/or revised

PolicyAssist™ consultants help health centers with good policy writing and management by applying their expertise in policy writing,  health center operations and environment, identifying gaps in policy compliance, applying templates and document formats proven successful in efficient and effective policy and procedure management, and setting in play staff training strategies to ensure appropriate staff receive the necessary training to fully and competently implement health center policies and procedures.  Below is a sample of what QFHC and PolicyAssist™ can offer to your health center.

Why Write Policies and Procedures?

The answer is easy. To satisfy various laws including HIPAA, HRSA, IRS, and other federal, state, and local laws, and accrediting entities such as The Joint Commission (JC),  the Accreditation Association for Ambulatory Health Care (AAAHC) and/or the National Committee for Quality Assurance (NCQA).  Additionally, the new IRS Form 990 asks whether nonprofits have certain policies relating to governance. Effective policies and procedures;

  • Help make instructions and guidelines definite and help in the interpretation of policies and procedures
  • Provide quick settlement of misunderstandings
  • Help reduce the range of individual decisions and discourage management by exception
  • Cover recurring situations such that managers can begin to make decisions that will be consistent every time
  • Set boundaries for jobs so that each employee knows in advance what response he or she will get from others when taking actions, making decisions, and giving responses
  • Provide protectionin the event of an audit or lawsuit

Policies vs. Procedures Defined

Often policies include day-to-day operating procedures within the body requiring protocols to be managed as a policy requiring heath center Board approval.  This can be a time and resource intensive process each time a protocol/procedure needs to be revised.


  • Describe the "What" the "Who" and the "Why"
  • Are a predetermined course of action established as a guide toward accepted business strategies and objectives
  • Are guidelines dictated by executives and/or extracted from regulations


  • Describe the "How" and are generally methods by which policies are accomplished.
  • Are a combination of one or more business processes
  • Identify the people, places, processes, forms, and actions necessary to carry out one or more policies or to support or influence other procedures

NOTE: Procedures that address a single process such as how to complete a form or cash a check should be referred to as "Desktop Instructions" or "Work Instructions" and complimentary to procedures.

Getting Started

First steps in establishing a policy framework BEGINS with 5 Agreements:

  • AGREE on the importance of a writing format and agree on which writing format to use in which situation.
  • AGREE on the use of a single writing format for policies and procedures or two writing formats for policy and procedure documents; and one desktop instruction format.
  • AGREE on communications media to be deployed.
  • AGREE on training methods to be utilized and repeated.
  • AGREE to write a "Policy on Policy Writing and Management" to capture the essentials of writing policies and procedures.

Procedures Instructions Writing Format

Remember procedures are the "How" of workflow processes and identify the people, places, processes, forms, and actions necessary to carry out one or more policies or to support or influence other procedures. The writing format should be different from the policy format and usually does not require Board review and approval. Below is a suggested format:

The Policy Attributes

Policy attributes are included in a policy to provide mechanisms for historically documenting the lifecycle of a policy, organizing identifiers, and applicability for distribution and training. Let’s look at common policy attributes.

Header Information (All Writing Formats have Header, or Title, information)

  • Logo
  • Title
  • P/P Number
  • Department/Operational Area
  • Effective Date
  • Review, Revision, and Approval Date
  • Approvals
  • Page Numbers
  • Scope

Quick Ways to Write Policies and Procedures from Canned Content:  There are two common methods to do this:

  • Method 1: The Quickest, but acceptance is difficult, is tofind or purchase a canned (generic content) policy or procedure you like from a website or book, don’t change a word, add your logo, and call it your own.  Unless you adapt content to your culture and people, buy-in is highly unlikely.
  • Method 2:  The Best method is to engage PolicyAssist™ consultants and assign at least one writer and/or form a cross-functional team, do research, use canned content for reference purposes only.  Interview users, brainstorm ideas, write a draft document, get it reviewed and approved, publish it, communicate and train.

And There’s More...

Once the policy document has been written, reviewed, approved, published, and distributed there is the act of implementing, monitoring for complete and accurate implementation, and sustainability of implementation over time. Guidelines to consider are:

  • Communicate the information and use the documents to train your employees
  • Manage the documents content and expiration dates
  • Work on improvements for the next revision
  • Update the document, publish the revision
  • Re-communicate and retrain... and so on

Communications are key to policy/procedure implementation because it’s a quick way to impart information about policy/procedure content.

Communication Methods can include:

  • Document management applications like PolicyPLUS™
  • Distribution of physical or electronic documents
  • Letters, press releases, newsletters
  • Paycheck stub or inserts
  • Posters, bulletin boards, or brochures
  • Team meetings, town meetings, staff meetings
  • Email messages or broadcast emails
  • Intranet news items

Provide communications in multiple ways to give the reader added ways to understand the material. Keep in mind that the "just once" communications method and plan is not acceptable and plans must be made to communicate regularly to ensure continued understanding on the behalf of the employee and to reduce the tendency to "resist change".

Training is critical to policy effectiveness and is defined as "to make prepared, to teach to be proficient, to undergo instruction, or to practice".  In business, training is the formal process used to develop in an employee the attitudes, knowledge, and skills an employee needs to make him or her capable of efficient performance (i.e., less time to carry out assignments).  Training methods include but are not limited to:

  • Document training management applications like PolicyPLUS™
  • Lectures, workshops, or seminars
  • Department or staff meetings
  • On-the-Job Training
  • Multimedia training and/or computer-based-training
  • Mentoring and coaching
  • Other creative training methods

The key to sustained implementation is to train and then to repeat training through on-the-job training and mentoring.

In summary there are necessary policy writing ingredients necessary to ensure success. These include:

  • Management commitment to write policies and procedures
  • Qualified writers---More than just an editor
  • Same writing format template used every time
  • Communications issued in multiple media 
  • Training offered in a variety of formats
  • Walk the talk from management
  • Mentoring and On-The-Job Training
  • Ensuring legal review of all relevant policies
  • Management of the documents and training with documentation
  • Regular timelines for policy reviews
  • Adding policy understanding as part of an employee’s annual evaluation


  1. Select a writing format and stick with it
  2. Write a policy on policy writing and policy management and stick with your decisions as you write policies
  3. Designate a policy writer and give this person the tools, time, and mobility he/she needs to be successful
  4. Don’t expect to be able to take a canned policy, make a few changes, add a logo, and call it your own if you actually want people to read and apply the content
  5. Put a policy writer in charge, follow the guidelines, and do it right the first time...so that readers might actually read the documents and apply the guidelines to their jobs
  6. Be proactive, as you are doing today, by reading this article, and learning tested methods for writing effective policies and procedures

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