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Hospice Policies and Procedures

Hospice policies and procedures provide a strategic framework for an agency’s entire operation, connecting visions, goals, regulation and ethical standards to internal operations. They provide structure and clear direction for employees. A policy manual guides managers to act decisively, fairly, legally and consistently.


A policy manual is absolutely essential in today’s complex, competitive and heavily regulated healthcare and work environment. There should be a single, current, authoritative source of guidance and information that the agency can use when making decisions. A policy manual serves as written documentation of the agency’s commitment to its employees, patients, stakeholders and the community it serves.


A hospice agency needs policies and procedures to define the guidelines for consistent behavior and actions within the company by all employees. These guidelines ensure that whenever events occur, they are handled in the same way. And since the policy and procedure manual sets standards within the agency against which all employees are measured, it also provides the means for disciplinary action that must take place for violation of these guidelines.



In order to understand the advantages of policies and procedures we need to know what they are, and the differences between them.


What is a policy and why is it important? – A Policy is a predetermined course of action, which is established to provide a guide toward accepted agency business strategies and objectives. In other words, it is a direct link between an organization’s ‘Vision’ and their day-to-day operations. Policies identify key activities and provide a general strategy to decision-makers on how to handle issues as they arise. This is accomplished by providing the reader with limits and a choice of alternatives that can be used to guide their decision making process as they attempt to overcome problems.


What is a procedure and why is it important? – The ultimate goal of every ‘Procedure’ is to provide the reader with a clear and easily understood plan of action required to carry out or implement a policy. A well-written procedure will also help eliminate common misunderstandings by identifying job responsibilities and establishing boundaries for the jobholders. Good procedures actually allow managers to control events in advance and prevent the organization (and employees) from making costly mistakes.


The Purpose of Policy and Procedure

  • Facilitates adherence with recognized professional practices 

  • Promotes compliance with regulations, statutes and accreditation requirements

  • Reduces agency practice variation and standardizes practices

  • Serves as a resource for staff and managers


Does My Agency Need to Review and Update Our Policy Manual?


A few signs that your policies and procedures need to be reviewed and updated might include:


  • An increase in the number of accidents or incidents

  • Higher service failure rates

  • More staff questions on normal operations

  • Inconsistent job performance by employees

  • Regulatory changes

  • Increased patient/family/referral source/community complaints



Policy manuals and their close relative, the employee handbook, should be an important part of the hospice agency. They are becoming increasingly more important as healthcare organizations become more diverse and complex. To ensure patient safety, positive employee and consumer outcomes, agencies need to ensure they have a well-defined and well-implemented set of policies and procedures in place.

Our Policy and Procedure Manual can be purchased as a paper version and/or an electronic version. Inquire here today.

What is Policy and Procedure?

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