Increasing Staff Members' Ability to Develop, Revise, and Access Department Policies and Procedures


Impact Statement: 
Inadequate documentation of policies and procedures is not just a hassle; it can also create confusion and redundancies that bog down staff’s ability to provide effective public health services and programs to the community. A small, rural local health department used quality improvement methods and tools to streamline their policy development and documentation process, which resulted in improved understanding and ease of use by staff.

Public Health Solutions District Health Department (PHS) was chosen as a beta test site for the Public Health Accreditation Board (PHAB) accreditation process. Through that process, overall strengths and weaknesses were identified. A major shortcoming across PHS was inadequate documentation of policies and procedures and inadequate documentation of decision making. The availability of a small amount of grant funds from the Nebraska Department of Health and Human Services (NDHHS) provided PHS with an opportunity to engage in a quality improvement (QI) project. Of the many areas in which such a project could be done, improvement of the policy and procedure process within PHS was selected because of its overall importance to successful operation and accreditation. Although no procedure is documented for the establishment of policies and procedures, PHS has followed a predictable sequence. The inherent problem is that PHS started operation without a basic policy framework. Consequently, many policies and procedures were prepared as needed. If there were time constraints, as was often the case, the procedures or policies were not adequately documented, secured, and placed in one location. This resulted in a patchwork of policies and procedures with many gaps. Further, these policies were not regularly reviewed and were not easily located. Therefore, some of PHS's operations were guided by staff memory or through reference books. Consequently, when those staff members left, those who remained often were not aware of previous policies or practices, resulting in an operational change that reflected the philosophy of the staff who remained. The result has been inconsistency in practice and service. The QI initiative is intended to reverse this by improving the quality of the process and using policies and procedures. A QI team was formed and included Jane Ford Witthoff (PHS director), Natalie Kingston (community development), Kim Plouzek (emergency response), Kim Buser (community health services), project lead Adam Zobel (administrative assistant), and other support staff. This QI initiative followed the Plan, Do, Study, Act (PDSA) cycle, and each of these steps is referenced in this submission. The PDSA approach was applicable and successful for this QI initiative because it allowed PHS to draft trial changes and assess their impact. During the Plan and Do stages, ideas for the change were created and tested, and, depending on the results, implemented. The Study stage was used to reflect on the new process and what changes still needed to be made, and the Act stage was used to implement an evaluation method.

Organization that conducted the QI initiative: 

Zobel, A. Public Health Quality Improvement Exchange. Increasing Staff Members' Ability to Develop, Revise, and Access Department Policies and Procedures. Fri, 10/10/2014 - 16:30. Available at Accessed May 29, 2024.

Submission Status: 
0 users have voted.


SaraWarren's picture
Submitted by SaraWarren on

Thank you for sharing this very important QI project. Sometimes while working in the public health arena the number of policies and procedures we have to adhere to can feel overwhelming. Easily locating what you need when you need it helps to increase efficiency and reduce stress. By developing tools, implementing standardizations and providing training you help to decrease the confusion. As you mentioned, needing to review a policy isn’t a daily duty, but when you do need that policy it is usually an immediate/can’t wait situation. Your project has given me some good ideas for possibly modifying our set-up. As well I appreciate you identifying some threats to keep a watch on.

2 users have voted.

Sara Warren

Submitted by mthorne on

Thank you for this information. Many Health Dept staff don't see their job as policy writing. This information will help us move our staff in the direction of acknowledging that we all need to be involved in policy/procedure writing.

1 user has voted.

Submitted by cstegall on

Thank you so much for sharing, this  has raised some good questions we can apply to our current QI inititiative in our EH program.  We are looking at how involving the staff in policy writting can lead to better compliance with the policy.  You gave our team some food for thought.

1 user has voted.

Carolyn Stegall, REHS

Submitted by lletts on

We also have done much work regardin gpolicy writing , accessing and adherance.  I really enjoyed your pre and post survey- we often forget to measure "perception from the eyes of user"



1 user has voted.
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