Policies and Procedures

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The Policies & Procedures Manual

Your policies and procedures manual should guide everything that your organization does.  It is the operating manual and most important document at your program, and it describes how you agency's process for any circumstance.  Also it will often include your Infection Control Plan, Emergency Management Plan, and any other aspect of your program.

The Role of the Policy Manual in a Joint Commission Survey

When surveyors arrive at your organization they expect to have access to a number of different documents.  The main item they are looking for will be your policies and procedures manual.  Prior to their arrival you are expected to take your existing policy manual that was designed to achieve state licensure, and crosswalk the Joint Commission standards into your existing policies, or create new policies when necessary.  This updated policy manual outlines to your staff (along with staff training) how to comply with relevant Joint Commission standards, and provides an explanation to the surveyor as to how these standards are applied at your organization.

Crosswalking Standards into a Policies & Procedures Manual

Crosswalking Joint Commission standards into your existing policy manual can be time consuming.  There are a lot of standards in the Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC), and most of those standards have multiple Elements of Performance that your agency must follow.  The rule of thumb is that if your state doesn't already require you to do something, you use TJC standards as the rules you follow.  In circumstances where your state and The Joint Commission both have requirements, The Joint Commission asks that you follow whichever rule is most stringent.  This is where having a strong working knowledge of all standards outlined in the CAMBHC becomes important.  If you have to go line-by-line through the CAMBHC and manually read every line of your policy manual and then complete a comparison of which rule is more stringent, your staff can be bogged down in this process for an extended period of time.

How We Assist Organizations with Policies & Procedures

Over the course of time Recovery Consultants has worked in the behavioral health care field, we have written a number of policy manuals for various different levels of care in many states across the country.  We are always refining our processes and always improving on the work that we have done, and have multiple sets of policies and procedures that have been updated over time with new or updated standards and rules as they are published.  


Sometimes providing your organization with a totally new policy manual makes sense.  In this case we would take one of the templates we have developed and reverse-crosswalk into your new manual. 


In other circumstances you may have staff on-site who have dedicated a lot of time in making sure your policies and procedures stay relevant to the rules in your state and what you do as an organization.  If this is the case, we will consult with you on areas of the policy manual that need to be updated, crosswalk relevant standards into your existing policies and procedures, and track the changes so we can go through and review each of them with agency leadership.  Reviewing these changes before they are approved is critical because often times there are different ways to be in compliance with Joint Commission standards, and we want to discuss with your leadership the best possible ways to apply the standards to your organization.


If your organization needs assistance in developing Policies and Procedures, or achieving accreditation through The Joint Commission, click the link below to contact us through our web submission form, or call us anytime at (866) 444-7272.

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