pen_and_paper.jpgPolicies are part of the Seven Elements model. There are also various regulatory requirements that organizations develop policies on specific topics. Producing “the policies” is often a condition of initial licensing or one step in a compliance investigation by a regulator. And policy development (even submission and prior approval) has also been made a condition of settlement in numerous cases. So you’d think that guidance about the government's view of what constitutes a “compliant” (or at least good) policy should be easy to find. You’d think…


  • The IRS is now requiring detailed information about governance practices of 501(c)(3) tax exempt organizations on their annual form 990 filings. Luckily they also provide information about what they are looking for.

  • To become Medicare Part A Providers (or change the ownership of an existing provider) organizations are being required to certify that they are in compliance with various civil rights laws AND produce copies of the policies that they rely on for that compliance. Luckily, the federal Office for Civil Rights has published sample policies.

  • AB 774 - California has not only set the requirements for hospital pricing policies – it also requires hospitals to submit their policies to a online, searchable database.

  • OSHA’s investigation guidelines describe specific content that should be part of hospital safety policies.

  • Required policy language relating to assistive devices for the deaf in a recent Consent Decree.

  • Beginning in 2014 Washington State is not only requiring hospitals there to have certain policies about Patient Rights but also to post them on their Internet site "where i[they are] readily accessible to the public, without requiring a login or other restriction."

Resources on Policy Writing

Sample Policies

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