The steps

  1. List the policies required by your scope (use the Quality Indicators Workbook)
  2. Start with Module 1: complaints, privacy, code of conduct, communication
  3. Module 2: governance, risk, incidents, HR, continuous improvement, document control
  4. Module 3: service agreements, care planning, service delivery, outcomes
  5. Module 4 (if applicable): environment, emergency, infection control
  6. Apply consistent version control to every document
  7. Sign and date every policy
  8. Train staff on each policy and record acknowledgement

Common mistakes to avoid

  • Copying policies from the internet without customising
  • Skipping Module 4 then needing it last-minute
  • Leaving policies undated and unsigned