Policies Serve Two Masters

A governance policy manual serves two masters. First, it is of greatest importance and value that the operators of an organization find what they need easily in their policies. Second, accreditation reviewers and auditors should be able to find what they need by reading through it when they need to.

Those ‘external’ reviews happen only annually or only once in several years. It is more important to organize the policy manual for the benefit of the operators because they are likely to pick up the book or search the e-file much more often.

In addition, in a recent policy review and enhancement, the directors of a board I was working with all agreed that if they pick the manual up to read cover to cover, it should read with continuity. If that is the desire, and it’s a reasonable one, then organizing governance policies to suit the external reviewers’ checklists makes no sense.

There is a way to assist in accreditation and audit reviews. Take the accreditation standards, for example, and one by one find the provision in the policies. Note the policy reference next to the standard, and note the standard next to the policy statement. If you can get a copy of the auditor's checklist, do that comparison as well.

In the process, you establish that the policies cover all the standards (of course, fill any gaps before the next review). Also, what you have then is a cross reference the reviewers can use to get through their work. In addition, amend the policies to include a parenthetical reference to the standards. Here’s an example, (Ref. COA V.4.02) where COA stands for the Council on Accreditation. Making that notation will avoid an inadvertent deletion later by a board that doesn't know its relation to accreditation.