Scenario:   The Client Services Director is unhappy with your Policy and Procedure regarding client flow. After discussing it with her key volunteers, she changes the policy so the client flow works better. Unfortunately, she does not tell the Nurse Manager or the Executive Director of the change. The Nurse Manager soon discovers the change when she observes that the clients/patients are not flowing to her in the manner that she was used to and, because of this, she is unnerved and not happy with the new situation. The Nurse Manager and the Client Services Director butt heads about the client flow change and the Executive Director must mediate a solution.

Does That Sound Familiar?
To avoid this sort of conflict and disorganization, the center should adopt a Policy and Procedure on Amending Policies and Procedures. This article discusses the proper method of updating an established Policy and Procedure Manual.

Policy & Procedure Manual
It can be an enormous job for pregnancy help centers/clinics to put together an updated, concise and applicable policy & procedure manual for its operations. Some policy and procedure manuals are so old, voluminous and convoluted that the task can be daunting. Written policies and procedures are the starting point for defensible, consistently applied, and ultimately effective organizational practices in every nonprofit.

Written Policies Serve Several Important Purposes.
They provide an effective way to communicate a common message to all staff. Written policies also provide admissible evidence of the organization's policies, should the organization need to defend its practices in court or at an administrative hearing. The absence of written policies leaves a nonprofit needlessly vulnerable to legal challenge.

Once official policies and procedures are approved and in place the manual must be implemented and followed, which means volunteers must be trained and regularly referred to the manual for direction. The Policies and Procedure Manual is a living document that is utilized regularly and updated as needed.

Annual Review and Approval
The Policies and Procedures Manual should be reviewed and approved annually by the Executive Director and the Board of Directors and (if your center is a medical clinic) by the Nurse Manager and Medical Director. Review of your written policies should help identify policies that are: 1) out of date, 2) poorly written, and/or 3) routinely ignored. There should be a page in the beginning of the manual for this annual review that shows each person's signature for approval.

If during the course of the year a policy needs to be added, updated or amended, the same key people need to approve the changed policy and a space should be provided at the bottom of the amended policy for each person's signature and the date of the approved change. Once approved, the new policy and its implementation should be immediately communicated to all relevant staff and volunteers. This will avoid any one from being surprised by a change in the policies.

Sample Policy and Procedure

Changing, Adding or Deleting Policies & Procedures

Policy:
In order to ensure the smooth flow of the organization's procedures, only approved personnel, upon approval of the Executive Director and the Board of Directors, may change, add or delete policies.

Policies and Procedures shall be reviewed and approved annually and may be changed, added or deleted before annual approvals as follows:

Procedures:

1. The Executive Director, Medical Director, Nurse Manager and Client Services Director are the only authorized parties to change, add or delete Policies and Procedures.
2. All interested/affected users of the Policy should be contacted in a timely manner when policies are being changed, added or deleted.
3. Changed, added or deleted policies MUST be approved by the Executive Director and Board of Directors prior to implementation. If the policy is medical or affects medical services, the Nurse Manager and Medical Director must also approve the policy. Only the Executive Director must approve non-medical policies.
4. A space shall be provided at the bottom of the changed, added or deleted policy for the date and for the initials of the Executive Director, Board Chairman, and as the case may be, the Nurse Manager and Medical Director.

Thomas Glessner
President of National Institute of Family and Life Advocates

This article was used by permission from NIFLA's e-newsletter for NIFLA members, Legal Tips, Volume XIV, Number 7, August 2007. Learn more about NIFLA at www.nifla.org.