Policies And Procedures


In 1978, the Uniform Guidelines on Employee Selection Procedures (UGESP) were issued. The guidelines are intended to establish a uniform basis of selection procedure criteria in the Federal sector. This guide imposes employers with the criteria by which the Equal Employment Opportunity Commission, the Office of Personnel Management, and the Departments of Justice and Labor would evaluate hiring practices to ensure adherence to merit principles.

The guidelines require employers to demonstrate selection procedures are valid in predicting and measuring performance in a particular job. Any selection procedure that has an adverse impact on any group will be considered discriminatory. Elements used in a selection process must be job-related, requiring criteria used to determine the candidates referred and selected be related to the job to be filled. The Guidelines provide employers with detailed information of recordkeeping requirements on disparate impact. (This is referred to as adverse impact in the Guidelines.)


One of the first important court cases to address the interpretation of Title VII of the 1964 Civil Rights Act was Griggs v. Duke Power Company. The driving force for this case was the requirement, by Duke Power, that laborers transferring to other departments have a high school diploma. This selection requirement failed under scrutiny since there were non-minorities who performed satisfactorily and achieved promotions though they did not have diplomas. In this case, the court emphasized that a selection device should measure the person for the job, not the person in the abstract. The tests did not have a demonstrated predictive affect on job performance.

The Supreme Court opinion in the 1971 landmark case of Griggs v. Duke Power Company reflected acceptance of the fundamental change in the definition of discrimination. This re-definition of discrimination was classified under the term “adverse impact” in the 1978 Uniform Guidelines on Employee Selection Procedures, an update and expansion of the original EEOC Guidelines that was jointly adopted by the EEOC, the federal Civil Service Commission, the Department of Labor, and the Department of Justice. More recently, Congress passed the Civil Rights Act of 1991, which was intended to reverse several Supreme Court rulings of the late 1980’s. This Act defined the statistically-defined adverse impact definition of discrimination.

J. R. Hackman and G. R. Oldham’s job characteristics model is an influential model of job design that explains in detail how managers can make jobs more interesting and motivating. Every job have five characteristics that determine how motivating the job is. These characteristics determine how employees react to their work and lead to outcomes such as high performance and satisfaction and low absenteeism and turnover.

Skill Variety

Task Identify

Task Significance



Be the first to comment - What do you think?



The ultimate goal of each administrator is to have a programme in which every member of the organization makes the same decisions given the same set of circumstances. It is impossible for the administrator to be everywhere a once, 24 hrs a day throughout the facility. Thus formulating policies helps in directing the activities of an employee 24 hrs a day in the facility. Properly developed policies ensure propriety and uniformity in handling patients and aid in maintaining good public relations.


A policy is the statement or general understanding which provides guidelines in decision making to members of an organization in respect to any course of action. They provide framework within which decisions must be made by the managers in different spheres.

Policies are general statements or understandings that guide managers thinking in decision making.

  • Weihrich and koontz

Policies define how the company will deal with stakeholders, employees, customers, suppliers, distributors and other important groups. Policies narrow the range of individual discretion so that employees act consistently on important issues.

– Kotler

Policies and procedures are means for accomplishing goals and objectives. Policies explain how goals will be achieved and serve as guides that define the general course and scope of activities permissible for goal accomplishment. They serve as a basis for future decisions and actions; help coordinate plans, control performance, and increase consistency of action by increasing the probability that different managers will make similar decisions when independently facing similar situations. Consequently, morale is increased when personnel perceive that they are being treated equally. Policies also serve as a means by which authority can be delegated.

Policies should be comprehensive in scope, stable and flexible so they can be applied to different conditions that are not so diverse that they require separate sets of policies. Consistency is important, since inconsistency introduces uncertainty and contributes to feelings of bias, preferential treatment, and unfairness. Fairness is an important characteristic that is attributed to the application of the policy. Policies should be written and understandable.


  • To communicate to each employee as exactly as possible what the management expects in any situation on the job.

  • To provide consistency in what employees decide in particular situations, under repetitive conditions.

Features of a policy

  1. A policy provides guidelines to the members of the organization for deciding a course of action and thus restricts their freedom of action. Policy provides and explains what a member should do rather than what he is doing.

  2. Policy limits an area within which a decision is to be made and assures that the decision will be consistent with and contributive to objectives.

  3. Policies are generally expressed in qualitative, conditional or general way. The verbs most often used in stating policies are to maintain, to continue, to follow, to adhere, to provide, to assist, to assure, to employ, to make, to produce, or to be.

  4. Policy formulation is a function of all managers in the organization because some form of guidelines for future course of action is required at every level. Policies may exist in all areas of the organization from major organizational policies to minor policies applicable to the smallest segment of the organization.


    • Policies are to be stated in writing and should be clearly understood by those who are supposed to implement them.

    • Policies should be based on the objectives of the organization

    • It should specify what is to be done

    • It prescribes limits and yardsticks for future action

    • It is reasonable and capable of being accomplished.

    • It should provide consistency in the operation of organizational functions

    • It should maintain balance between stability and flexibility


  • The key function of policy is to unify and give direction to plans.

  • Policies help managers plan by guiding operating decisions and often pre making them.

Be the first to comment - What do you think?


      • Policy formulation; formulation of policies is mainly by top management. Facts must be gustered and analyzed, members in the organization must be consulted.

      • Policy communication; once a policy is formulated it must be communicated to those who are ultimately responsible for its application. Policy manuals, company handbooks, written memorandums, broad letters and announcement etc. generally passed into the service in order to disseminate the policy.

      • Policy application; policy decision rest basically on human judgement and intuition. Consistency in applying the policy is very essential and at the same time some flexibility is necessary in day to day affairs.

      • Policy review and appraisal; hospitals will have a standing committee for the review of policies as a part of organizational structure. Policies need to be revised in the light of new environmental circumstances.

Types of policies;

1. Formulated policy; A formulated policy is one which is specified by the organization for providing guidelines to its members. Most of the policies in private sector organizations fall in this category as every organization formulates various policies on different aspects. Such a policy flows from higher level to lower levels in the organization. This policy may be broad giving general guidance for the action or may be spelled completely so as to leave little scope for definition and interpretation.

2. Implied policies; Sometimes policies may not be clearly stated, and the action of managers particularly at the higher levels provide guidelines for actions at the lower levels. Sometimes, the organization has clearly expressed policies for its image but it is not able to enforce these. In such a case, the action of the decision maker, consciously or unconsciously, depends on his own guidelines, prejudices and whims. Moreover, in the absence of any specific guidelines, decision is based on individual interpretation of the situations and consequent actions.

3. Imposed policy;

Imposed or external policies are thrust on an organization by external forces such as government or labor unions. These agencies may either provide complete guidelines on the subject matter or provide a broad framework for devising specific policies. Policies of the organization must conform to local, state, and federal laws. Collective bargaining and union contracts direct labor policies. Professional And social groups – such as the American Nurses Association, National League for Nursing, church, school and charitable organizations mold policy.

4. Appealed policy; An appealed policy arises from the appeal made by a subordinate manager to his superior for deciding an important case. The need for such an appeal may arise because the particular case has not been covered by any policy. The appeal is taken upward and the decision made on the case sets a precedent which becomes policy providing guidelines for deciding similar cases in future.


  • Policies serves as guides in decision making

  • Policies create standardization

  • Policies save time

  • Policies control the performance

  • Policies define an area within which a decision to be made to ensure that the decision will be consistent with and contribute to the objectives of an organization.

  • It refers to all employees.


A disadvantage of policies is the reluctance to revise them when they become outdated. Managers should review policies periodically, and if that fails, personnel can appeal for a revision.

Be the first to comment - What do you think?


The major policies that give an overall direction to operations are likely to be in the following areas

  • Growth; growth policies give answers to such questions as these; how much growth should occur? How fast? Where? How should it occur?

  • Finance; every business enterprise must have a clear policy for financing its operations.

  • Organization; it answers practical questions-eg; How centralized or decentralized should decision making authority be? What kinds of departmental patterns are more suitable? How should staff positions be designed? Naturally, organization structures furnish the system of roles and role relationships that helps people accomplish objectives.

  • Personnel; there can be many policies in the area of human resources and relationships. They deal with such topics as union relations, compensation, selection, hiring, training and appraisal, as well as with special matters such as job enrichment.

  • Public relations; policies in this area can hardly be independent; they must support other major strategies and efforts. They must also be designed in light of the type of business, its closeness to the public, and its susceptibility to regulation by government agencies.

  • Product of services; A business exists to furnish products or services. In a very real sense, profits are merely a measure- although an important one – of how well a company serves its customers. New products or services, more than any other single factor, determine what an enterprise is or will be. The key questions in this area will be summarized as follows;

What is our business?

Who are our customers?

What do our customers want?

How much will our customers buy and at what price?

What advantages do we have in serving customer needs?

What profits can we expect?

What basic form should our policy take?

  • Marketing; marketing policies are designed to guide managers in getting products or services to customers and in encouraging customers to buy.

The planning process involves defining, communicating, applying and maintaining policies. The development of a policy can originate anywhere in an organization and should involve personnel who will be affected by the policy. They have valuable information for sound policy formation and can ensure that the policy will be implemented. Before writing a policy one must consider whether there are specific, recurring problems, how frequently they occur, whether they are temporary or permanent in nature, and whether a policy statement would clarify thinking and promote efficiency.

When policies are written, the purpose, philosophy, goals and objectives should serve as guides. It is advisable to have the policy statement reviewed and approved by superiors and the affected managers before the policy is formalized. Policies should be written in a specific, concise and complete manner that is easily accessible to all personnel to whom the policies apply. The manual will be well organized if policies are classified, noted in the table of contents, and indexed by topic.

Once a policy has been stated and approved, it is applied. Policy formation is a continuous process so the policy is continually reappraised and restated as necessary. Periodic analysis and evaluation of existing policies can suggest the need for revision. Personnel should be encouraged to help formulate, review and revise policies.


Name of policy ————————————————

Date of review————————————————–

Reviewer ——————————————————–

(Name) (Service)

INSTRUCTIONS; Please circle the number that most accurately reflects your response to the following questions. Please check at the bottom your recommended action.







Is there a need for the policy?




Is the policy relevant to this institution and staff?




Is the policy consistent with Indiana university hospitals nursing services philosophy?




Is the policy in conflict with any other hospital or nursing policies?




Does the policy creates any inequities among hospital staff or patients?




Is the policy reasonable?




Is the policy clearly written so that anyone unfamiliar with the subject can understand it?




Is the information accurate?




Is the policy complete?



Additional comments;



– No action required – Revision required – remove from

Approved as written (changes attached) (justification attached)

Be the first to comment - What do you think?

Contents of a procedure

Writing procedures demands a consistent format that considers

  • Definition

  • Purpose

  • Who performs activity?

  • Steps in the procedure

  • Materials needed and how to locate, requisition and dispose of them

  • Expected results, precautions, legal implications

  • Nurse patient and physician responsibilities and appropriate charting



Name of procedure; ————————————————————-

Date of review; ——————————————————————-

Reviewer (s) ———————————————————————-

(Name) (Title) (Service/unit)


(Name) (Title) (Service/unit)

Note; The reviewer may wish to carry out the procedure exactly as written before addressing the questions below)

Please circle the number that most accurately reflects your response to the following response.

* When procedure differs from practice, please note discrepancies on separate sheet of paper. Please write recommended revision on separate sheet of paper and return to ………….. by … …………








Does the procedure accurately reflect all equipment/materials necessary to carry out the procedure

  • safely/

  • competently?





Does the procedure reflect equipments used at IUHs?





Is the sequence of steps correct?





Is the sequence of steps complete?





Are the contraindications if any, clearly identified?





Does the scientific rationale provide a meaningful reason for each intervention?





Does the procedure reflects results of current research and state of the art clinical nursing practice?





Does the procedure reflect current clinical practice at IUHs?





Is the procedure in conflict with any other hospital or nursing services policies/ procedures? If so please list.




Additional comments:



The procedure is correct – Discrepancies noted. – Recommended

as written. Recommended revision procedure not

attached. be adopted.

Recommended adoption

Of procedure

Be the first to comment - What do you think?



Policies are carried out by means of more detailed guidelines called procedures. They indicate a standard way of performing a task. Procedures supply a more specific guide to action than policy does. They help to achieve a high degree of regularity by enumerating the chronological sequence of steps.


A procedure can be defined as a series of related tasks that make up the chronological sequence and the established way of performing the work to be accomplished.

– Terry and Franklin

Policies give rise to procedures. For eg., an organization may have a policy of promotion based on seniority. To implement this policy, procedures must be established to determine the seniority of the employees and promoting them to suitable positions.like promotion procedure, there can be procedures for different activities such as placing orders, selecting employees etc.

Manuals; it is a good practice to assemble all the directives concerning the administration and procedures in a manual which can be available for reference. These directives, in general, fall under three headings;

  • Administrative procedures issued by the administrative office and referring mainly to regulations. This is essential for the maintenance of discipline.

  • Unit procedures outlining the procedures to be used in a unit.

  • Procedure manuals Eg; nursing procedure manual, laboratory procedure manual.

Procedure manuals provide a basis for orientation and staff development and are a ready reference for all personnel. They standardize procedures and equipments and can provide a basis for evaluation. Good procedures can result in time and labor savings. Improvement in operating procedures increases productivity and reduces cost.

Characteristics of good procedure

  1. Based on facts; A procedure should be based on adequate facts of the particular situation and not on personal guesses or whims. Due consideration must be given to the objectives, the physical facilities, the personnel and the type of work. The procedure should be such that it should not hinder efficiency. The end results govern the steps taken and are a prime consideration. The steps should be complementary and lead cumulatively to the accomplishment of the desired goals. Each step should be justified, fulfill a definite need, and in proper relationship to the remaining steps of the procedure.

  2. Stability; A procedure should possess stability in that it provides a steadfastness of the established course, with changes made only when fundamental modifications in the factors affecting the operation of the procedure occur. Stable procedure provides continuity in the action and the people get well versed with the system this helps in efficient execution of actions.

  3. Flexibility; Flexibility of procedure is desirable in order to cope with a crisis in emergency, special demands or adjustment to a temporary condition. Balance between flexibility and stability should be maintained.

  4. Updated procedures; there should be continuous review of procedures so that their utility is ascertained. In many cases it happens that a new procedure is added without deleting or modifying the existing ones.

  1. Minimum procedures; Every procedure costs something to the organization interms of manager’s time, paper handling, delay and lack of responsiveness to change. More the number of procedures more are the cost on the part of the organization. Therefore, their number should be kept to the minimum possible; otherwise procedures become more important than results themselves.

  2. Procedures as a system; Procedures, to be more effective, must be recognized as a system of interrelated activities of a network. The designing of the procedure should be linked with the organizational relationship and all factors should be taken into account, which affect these relationships. This is possible only when a comprehensive view of procedures and their working are taken into account and suitable modifications are made therein.

Be the first to comment - What do you think?


Initial review by affected groups/ individuals

Proposal developed and sent to policy procedure review committee



Need identification

Executive nursing committee authorization

Revised drafts

Final review by PPRC




Be the first to comment - What do you think?

Difference between policy and procedure



  • Policy provides guidance for managerial thinking as well as action.

  • Policy is more flexible because it prescribes the areas of discretion to managers.

  • Policy is more pronounced at higher levels.

  • Provides guidelines to action by prescribing how an action can be performed step by step.

  • Less flexible because it prescribes the exact sequence of the activities without scope of any variation.

  • Procedures are more prevalent at lower levels.

An article regarding “The clinical response to brain death: A policy proposal is written by Burck R et al, which suggests that a universal policy should be adopted whereby all institutions develop the same guidelines concerning when and how treatment should be withdrawn on their brain dead patients. Such policy guidelines may not extinguish the misconceptions, misunderstandings and discomforts that are present with a diagnosis of brain death, but it would certainly allow for more consistent actions on the part of the caregivers.

An article regarding “Advanced practice nursing: Leadership to effect policy change” is written by Mc Lennan, which says by using Lomas framework for connecting research and policy to guide strategic planning, an APN programme was successfully implemented in a traditional medically oriented oncology centre with collaborative relationships established with two faculties of nursing. Focusing on the organizational culture, stakeholder values and beliefs were essential ingredients to facilitate change.

Be the first to comment - What do you think?



  1. Tommy AM. Guide to nursing management. 4thedn.Philadelphia: Mosby publications; 1992.

  2. American Hospital Association; The Hospital Admitting Department. Second edition.U.S.A.: American Hospital Publishing Inc;1986.

  3. Koontz H, Weihrich H. Management ; A global perspective.10th edn. Newyork: Mc graw Hill inc; 1994.

  4. Massie JL. Essentials of management. 4th edn. NewDelhi: Prentice Hall of India PVT LTD; 1996.

  5. Tabi SA. Hospital and health service administration; Principles and practice. NewDelhi: Oxford university press; 2001.

  6. Prasad LM. Principles and practices of management. NewDelhi: Sultan chand and sons educational publishers; 2001.

  7. Nancy. Principles and practice of nursing. 3rd edn. Indore: NR Publishing House; 2000.


  1. Burck R et all. The clinical response to brain death: A policy proposal. Journal of nursing administration. April- June 2006;8(2): 53-59.

  2. Lennan M, Cummings G. Leadership to effect policy change. Journal of nursing administration. Feb 2005; 35(2):61-65.

Be the first to comment - What do you think?

« Previous Page