How Organisations Can Create Policies That Actually Improve Care

Last Updated: 11 July 2023

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In general, policies and procedures are guides that make sure organisations are following rules and respecting regulations.

However, great policies and procedures also ensure that organisations and employees operate at their highest possible standard in their day-to-day practice.

But how can organisations develop policy that actually creates a culture of efficient, effective and quality care? How can organisations make sure policy is passed from managers to employees all the way across to patients and clients?

In this article for Ausmed’s Industry Insights, we’ll cover the purpose and benefits of having great organisation policies, as well as some simple ways you can close the gap between theoretical policy and everyday staff procedures.

What is the purpose of effective policies?

In their barest form, policies exist to keep staff and clients safe. Policies result in the performance of tasks and routines efficiently and consistently across the organisation, thus limiting the presence of individualisation on the part of staff. However, well-formed policies do much more than just keep everyone safe. They can also result in:

  • higher-quality care provided by staff, which generally results in less staff turnover
  • the provision of better-quality service
  • the ability to easily and accurately track performance metrics
  • protection from potential litigation.
There are no downsides to creating high-quality policies. Even the time spent creating these policies is beneficial: interviewing staff creates organisation loyalty, and providing innovative policy shows consumers and stakeholders that your organisation is mindfully and purposefully growing.

How can your organisation make sure policies genuinely improve care?

Create a policy team

Flat vector illustration of a smiling, diverse policy team with their hands on each others shoulders

A policy team provides more depth to the creation of your organisation’s policy and procedures, especially when compared to a lone compliance officer or learning and development manager.

A policy team can be made up of members of various departments and leaders within specific teams. Each person should bring a new perspective to the discussion surrounding relevant, high-quality policy creation, so people from all levels of the organisation should also be present – from new employees to team leaders to management and executives.

When it comes to the actual writing and editing of policies and procedures, this should fall to a smaller group within the team. Using Ausmed’s Policy Management System, the policy team can easily maintain version history, especially during a review or development proces

Audit current policies

A successful audit is an investigation into an organisation’s current policies and procedures, and results in the creation of high-quality, relevant and effective policies and procedures.

By auditing current policies, you’re saving yourself time and resources in the long run. If you don’t complete an audit before developing new policies and procedures, you’re likely to create duplicate policies that provide staff with contradictory information. That being said, a thorough policies and procedures audit is more than just an inventory of current documents.

An audit also needs to take into account:

  • where policies and procedures are stored and how staff access them
  • where metrics are stored and how staff who need them access them
  • who has ownership of each piece of policy or procedure and how to contact them
  • how policies and procedures are enforced amongst staff

Before launching into an audit, remember that they can take months to complete. It’s essential that you set out an in-depth plan for yourself and your team, and that you hire contractors (if possible) to reduce the time it will take.

Create a standard format

A standard format means that staff can navigate policies faster and with more accuracy.
By no means is the aesthetic of a policy more important than the content. However, a consistent and easy-to-read standard format will make it far easier for your staff to repeatedly refer to policy during their everyday practice.

When creating the standard format upon which all of your policy documents can be built, use online resources to help with the design. The following are some great resources to explain the use of certain formats and the importance of components such as white space and subheadings:

One great tip from Ausmed: create a quick reference guide for each policy or document. When staff need to scan for general information – maybe when on shift or checking a statistic relating to your organisation – a quick infographic guide (with small vectors and big numbers) can save them a lot of time and energy.

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Utilise specific metrics

How can you know if your policies are working if you can’t measure their success?

It’s absolutely integral to attach measurable objectives to each piece of policy so that you know whether they’re doing their assigned job. Metrics can be any number of different things: the number of times a policy has been viewed by staff, a change in the number of staff effectively completing a certain task, or an increase in employee engagement regarding patient or staff advocacy.

The creation – or improvement – of policy metrics will rely heavily upon the depth of information gathered during the audit. If a policy was previously viewed a lot but hardly enacted, the measurable objective should be related to the enactment of that policy’s topic/objective.

For example, the measurable objective for a commonly-viewed personal hygiene policy could be the number of infections that present in the organisation over the next year.

However, if the previous version of the personal hygiene policy was hardly viewed by staff, the measurable objective – at least for the first few months – could be the number of times the policy was viewed by staff. Using Ausmed’s Policy Management System, you could track this using a single report that would break down which staff members did or did not view the policy, which areas of the organisation are lacking in this area based upon views, and at what point in the reporting period these staff viewed the policy.

All of this information can help to inform your organisation’s policies and procedures, from creation and publication all the way to implementation and revision.

How can organisations make sure their policies are showing through in the care their staff are providing?

In short: through their employees. Even if an organisation has incredible policies and procedures, if they’re not built into the everyday practice of employees, they’re essentially rendered useless.

Photograph of a female nurse crouching down and taking care of an elderly man in a wheelchair


Where are your staff when they’re accessing policies and procedures? How long does it take for them to find them? Is the language in each report easy to understand and built for a layman’s interpretation?

All of these questions are key to understanding whether your policies and procedures are accessible or not. If your staff struggle to locate or engage with these documents, they won’t be able to implement the designated standards into their practice.


Distribution of a new policy is a key stage in implementing new organisational policies and procedures, and the efficacy of this stage falls to the policy team.

How are staff going to be trained on this new policy? When will existing staff sign off on it? How can you make sure nobody falls through the cracks, whether they’re on leave or sick during training day?

Ausmed’s Policy Management System centralises policy management, meaning policies can be assigned to groups or individuals for acknowledgement. You and your policy team won’t have to chase someone up while at work, or spend your precious personal time desperately trying to call someone who didn’t turn up to training day. Just send them the policy and wait for a notification to tell you that they’ve acknowledged it!

Consistent reviews

The policy team should set up a policy review routine. This will keep policy fresh and relevant while giving staff regular opportunities to offer insights that could inform policy creation or development.

Annual reviews are generally recommended as a bare minimum, but when you have a whole policy team working together, reviews every six months are relatively easy and simple to organise.

Just make sure you keep staff abreast of when these reviews are so that they have ample time to review their needs, make a note of them, and send them over to the policy team!


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