Are you familiar with the steps involved in creating or updating an organization's policy?

As previously mentioned in Developing And Maintaining a Policy: Part 1, there are essential steps to take when creating or changing a policy for an organization. Let's take a closer look at steps 1 and 2 and use examples from the healthcare industry to demonstrate.

To ensure that an organization's needs and commitments are met, it's crucial to provide accurate and crucial information during all three policy phases. In this article, we'll take a closer look at the Pre-Policy development phase.

The key activities live in 3 policy phases for your action plan:

Phases Steps 
A. Pre-Policy Development Phase

1. Identify a policy owner and policy name 

2. Identify the internal resource references and affected departments

B. Policy Development Phase 

3. Identify the external related source(s) for the basis of the policy

4. Search, research, and investigate

C. Post Policy Development Phase 

5. Identify continued maintenance activities

6. Collaborate with policy committee and inter-departmental stakeholders


Phase A. Pre-policy development phase: 

Regardless of your situation or specific policy, there are essential successful action plans to implement during pre-policy, policy development, and post-policy phases which all lead to a high-quality outcome for the life cycle of a policy.

Step 1a. Identify a policy owner.

In many cases, a policy does not have a designated owner, or the owner is unaware of their ownership. In some rare instances, an organization may not assign individual policy ownership. Despite the lack of ownership, this aspect remains crucial and necessary

For optimal policy ownership, keep the following dos and don’ts in mind:

  • Do list a policy owned by a specific "Title" instead of an individual name to allow for flexibility in case of personnel changes.
  • Do consider naming a policy owned by a role/title and department name. For example, the "Case Management Director/Case Management Department" can represent a staff resource contact and responsible owner.
  • Do select a policy owner who will be responsible and a subject matter expert on the policy contents.
  • Do ensure that the policy owner can attend future webinars and conferences related to the policy for critical knowledge access.
  • Don't assign an entry-level staff member or a non-subject matter expert as the policy owner.

Step 1b. Identify a policy name.

Keep the name simple and directly reflecting the content for easy understanding by outside parties. 

Consider these tips when naming your policy:

  • Choose a clear and concise name that explains itself.
  • Get feedback from others on the potential names you've come up with.
  • Avoid using complex names or acronyms that could be difficult to understand.
  • Be open to updating the name over time, especially if you need to consolidate multiple policies.


Step 2. Identify internal resources and other affected departments.

Be cautious about working in a silo. It is critical to always look for other affected departments or other operations that may intersect with your policy.

Consider the following “Dos” and “Don’ts” for the best identification of resources:

  • Do identify early and work with a collaborator if one exists whose work/knowledge may intersect with your policy.
  • Do identify specific internal references/resources such as other related department policies, desktops, and job aides.
  • Do work closely with the “Policy Committee” if one exists, to identify overlapping policies and artifacts.
  • Do identify and utilize or create an organization’s “Policy Template” for consistent format and style.
  • Don’t work in a silo or without broad communication throughout your organization.

Next month we will examine the policy development phase and step 3 and 4 of this 4-part series.


Partner with Impresiv Health 

Impresiv Health provides comprehensive consultative services in the area of policy development, implementation, and training to meet all your healthcare policy needs for software operations, legislation requirements, general operations, and/or regulatory/accreditation requisites. Impresiv has created and updated multiple policies for nationally recognized healthcare companies and welcomes the opportunity to work with you. 

Connect with us through our website or reach out directly to Chris A. Brown, Chief Growth Officer at to start a conversation. We look forward to assisting your policy needs and providing you with the most efficient solutions. 

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