Before putting pen to paper, think about what you want to achieve by issuing this policy. Consider the following questions to outline your policy:
Why are you creating this policy?
To satisfy legal/regulatory requirements?
To address an operational need?
To correct an issue/risk identified?
To improve processes?
To clarify requirements/obligations?
What is required to be included in the policy? (this is a good starting point for the outline)
Who needs to be involved in drafting this policy?
Do other departments/offices need to be consulted with?
Is there a need for collaboration?
POLICY vs. PURPOSE vs. PROCEDURE: What information pertains to each section?
Policy – Establishes the overarching framework for organizational requirements, standards of expectations and decision-making.
Address the who, what and when
Who is responsible for administering this policy and overseeing its procedures? (typically this would be the Policy Owner)
Always use Department/Office names and/or titles.
What is the policy?
When does this policy apply?
The policy section should embody any legal/regulatory requirements. A succinct summary of the requirements is sufficient. Never copy the legal/regulatory text.
Reference statutes where applicable.
Policy language should be broadly and generally drafted. Policies should not require frequent updates.
Purpose - Why do we have this policy?
What is the goal of this policy?
Procedure – Describes the action items, processes, or workflows to inform the reader how to comply with the policy.
Address the how, when or who
How – Describe the detailed activities or processes in place to comply with the policy
When – It is important to include specific time frames, deadlines, important dates, etc.
Who – Include relevant departments/individuals (by title) who is responsible for any step of the process or can be contacted for additional guidance
Include references to other guidance documents or policies that are relevant to this policy
SCOPE: Who’s Your Audience?
Determine who this policy applies to?
Use the following standardized language unless there is a group of individuals not included in the definition:
“This policy applies to all WCM workforce members as defined below”
Everyone employed by or associated with WCM (employees, students, faculty, researchers, clinicians, vendors, business associates, clients, patients, etc.)
Limited group of individuals (i.e., only clinical staff, the research department, faculty, students, etc.)
Consider who will read this policy for guidance. Our policies are not only used and read by WCM staff. They may also be read by individuals external to WCM such as patients, vendors, clients, regulators, attorneys and the court of law.
NOTE –Always keep in mind that regulators and the court of law should be presumed to be readers of our policies. Policies may come into question during an audit, external review, investigation, or legal proceeding.
Is the policy geared more toward management or staff?
WRITE: Clear, Concise and Consistent.
Clear – Avoid ambiguity. Aim to convey the message in such way where there is little room for misinterpretation.
Mandatory (must, shall) vs. optional (may, should, could) language
“should” implies that an action may not be necessary or required
“shall” imposes an obligation
“must” is obligatory or requires action
Concise – Refrain from frequent use of jargon, qualifiers and long sentences.
Do not over include details. Include only what is relevant to the reader.
If you are unsure whether certain information should go in the policy or in an internal document, determine who needs know the information. If the information contains specific procedures to be used by staff internally (or by a limited number of individuals), then it should be written in a SOP, handbook, guideline, etc.
Consistent – When writing a policy, cross reference other similar policies and policies within the same group to make sure there are no inconsistencies.
NOTE - When there are two or more policies containing the same definition, only one definition should be used unless there is a specific reason (i.e., the term is defined differently in two separate law/regulations) as to the difference.
Format – make sure you are using the most recent standardized policy template [link here]
Font – Arial
Font Size
Headings – Size 12
Body – Size 10
Header Text – Size 8
Footer Text –
Body Formatting
Main Section Titles (A. B. C. D. E. …) – Bold, no underline
Subsection Titles (a. b. c. d. e. …) – Bold, no underline
Grammar Tips:
Use present tense
Active voice – the subject of the sentence performs the action (ex. The Director of Policy developed this guidance.)
Use gender inclusive language (gender neutral and gender sensitive)
Spell out acronyms the first time they are used with the acronym in parentheses
