Revising Policies and Procedures during the COVID-19 Crisis

Many organizations have made a commitment to review and revise policies and procedures to respond to the rapidly evolving impacts of COVID-19. It can be crucial to document decision-making processes to help lessen current and future confusion around decisions made. During a crisis, policies and procedures are often modified based on pertinent published medical literature, national and state guidelines, or expert consensus, which continues to evolve relative to COVID-19.
Organizations should clearly identify why policies and procedures are being created, when they go into effect, and how long they it will be in place. Providing a timeline for training and implementation is essential. A practical format for writing policies and procedures can be given in eight parts:

  • Responsibilities
  • Procedures
  • Document Approvals
  • Change History
  • Purpose
  • Persons Affected
  • Policy
  • Definitions
Types of Policies and Procedures

Here are some of the different types of policies and procedures physician practices and facilities should consider amending under crisis circumstances:

1. Administrative Policies
These policies cover the day-to-day business operations and ensure the organization has the resources it needs to operate. During a crisis, the emergency preparedness plan typically goes into effect, but other administrative policies may be created to supplement the plan. The following organizations offer guidance on developing or revising administrative policies:
Centers for Disease Control and Prevention (CDC)
Federation for State Medical Boards (FSMB)
American Hospital Association (AHA)
2. Patient Care Policies
These policies are guidelines for how physicians, nurses, and staff care for patients and should be the most comprehensive. For example, it is recommended that you review the CDC for COVID-19 related situation updates, cleaning guidelines, and strategies for healthcare professionals. The following organizations offer guidance for patient care during a crisis:
Centers for Disease Control and Prevention (CDC)
World Health Organization (WHO)
National Institute of Health (NIH)
American Hospital Association (AHA)
3. Medication Policies
These policies are guidelines established to promote the health and safety of those persons served by ensuring the safe assistance and administration of medication and other treatments and other necessary procedures. In times of crisis, it may be necessary to revise existing policies regarding prescribing practices, medication supply shortages, and medication refills. The following organizations offer medication guidance:
Centers for Disease Control and Prevention (CDC)
American Medical Association (AMA)
Drug Enforcement Agency (DEA)
4. Health Information Technology Policies (Health IT)
These policies govern the systems designed to store, share, analyze, collaborate and safeguard patient data and diagnostic details. During a crisis, it may be important to revise policies pertaining to Virtual Private Network (VPN) capabilities, remote worker access, cybersecurity protocols, and other relevant Health IT concerns. Review the following organizations for Health IT guidance:
Healthcare Information and Management Systems Society (HIMSS)
U.S. Department Health and Human Services Department (HHS)
American Health Information Management Association (AHIMA)
5. Human Resources Policies
These policies govern employment practices, working conditions and workplace processes. In accordance with applicable laws, employers should establish human resource policies for employees that are unique to a crisis or pandemic. You may need to share updates that impact core staff, contract workers, and third party vendors, including topics such as pay, benefits, and employee safety guidance. Review the following worker safety resources for additional guidance:
Occupational Safety and Health Administration (OSHA)
U.S. Department of Labor (USDOL)
Kansas Department of Labor (KSDOL)
Equal Employment Opportunity Commission (EEOC)

Risk Management Recommendations
Please note the following recommendations should be implemented in a manner that aligns with the organization, leadership, care teams, and patient flow:

  • Recognize new policies, procedures, and protocols may be necessary to develop or revise to provide direction on topics. Keep in line with new recommendations as they are announced.
  • Stay informed about the local COVID-19 situation. Stay abreast of guidelines and requirements for crisis standards of care and clinical ethics from your state and local health authorities. Know where to turn for reliable, up-to-date information in your community.
  • Be prepared to share resource compilations with key clinical and administrative leaders and update the resources as information changes.
  • When drafting and revising policies, keep in mind that the guidance you rely on should be used within the proper context. This means the information should be adapted to your facility based on the resources available at the location where the medical professional services are being provided and any other unique circumstances.
  • Furthermore, the guidance you review is not meant to be complete or exhaustive. The COVID-19 pandemic is an evolving situation, and the CDC is providing new guidance on a regular basis. Remain flexible and open to making midcourse corrections as needed.
  • Develop your implementation plan to outline the details of your strategies, including lead responsibility and timelines for managing change at the front line.
  • Clearly communicate to staff when policies and procedures have been approved and the dates they go into effect.

This information does not constitute clinical or legal advice and is only being offered to help organizations craft their own approach to drafting policies and procedures during a crisis. Organizations are encouraged to provide accurate and consistent information to employees reflecting the guidelines of the CDC and other governmental agencies.