Policy and procedures are documents that define a specific goal within an organization and then provide specific methods of how the goal will be carried out. They document standard practices and usually require updating and revision when an external source (accreditation, funding source, government regulations, etc.) or internal process requires changes in practices. Plans or “written” plans are created by the organization in various areas (cultural competency, risk management, information technology, accessibility) and facilitate goal setting and planning by the ownership and/or management of an organization. They are, in effect, similar to the clinical plans for persons served, in that they contain goals, objectives, methods, timelines, and persons responsible for completion of the objectives.

Our policy and procedure documents and our written plans provide excellent examples of different formats for meeting the accreditation standards.