Policy Management and Storage Knowing what you have and where it is.

Policy Management and Storage

Knowing what you have and

where it is.

Objectives for this Section

Identify an appropriate filing system for your agency.

List at least two issues to think about when choosing a filing system.

Identify at least two different filing systems.

Housing Policies

Filing system used is linked to the capacity and preference of the organization.– Binders kept in offices– Filing cabinets or hanging files in central

administration– Internet/Intranet– Combination of methods

Internet/Intranet Storage

Involve your Information Technologist (IT).– Develop specific pathways that will assure

access to policy and procedures.– Secure space in the system that does not

conflict with other computer functions.– Develop a backup plan so that the information

can be safeguarded.– Make sure staff can access them.

Binder/Filing Cabinet Identify just the right spot.

– Will the policies be safe?– They won’t get rained on.

– Critters can’t get them.

– Gremlins can’t disrupt them.

– Are they where staff can find them?– Is there a desk so that staff can read them in the area?

– Is there adequate light and access to a telephone?

– Are they near where staff will need to apply them?

– Are there enough sets of policies (multiple floors/districts)?

Filing System

Why have a system?– Prevents duplication of policies.– Provides a catalyst for thinking through why

you are even writing the policy.• EX: If the agency has a confidentiality plan do you

need a separate policy in each program, or just reference the agency plan?

– Expedites finding policies when needed.

Establishing a Filing System

Building a user friendly filing system is similar to how you fill a bucket to get maximum load.– Start with the big rocks.– Next add the smaller stones– Then add the pebbles– Finish with the fine sand.

Categorical Filing System - Step 1

Establish major categories - Big Rocks– Make sure the categories make sense to staff.– Suggestions

• Board of Health

• Governance

• Administration

• Emergency Response

• Occupational Health and Safety


Establish major categories…continued.• Occupational Health and Safety

• Facilities Maintenance

• Risk Management

• Clinical Programs

• Community Services Programs


Indexes with each heading facilitate finding policies.– Whether to insert indexes here under the major

categories or to insert them later will largely depend on how many policies you have.


Sub-headings - Smaller Stones– Ex: Occupational Health and Safety

• Blood-borne Pathogens Policies

• TB Control and Prevention Plan

• Material Data Safety Program

• Ergonomics Control Plan


Add groupings where needed - Pebbles.– Ex: Blood-borne pathogens

• Clinical applications

• Laboratory applications

• Community Services applications


File by title….the sand– Ex: Category...Occupational Health & Safety

• Sub-heading…Blood-borne pathogens– Grouping……Laboratory

• Title…….Collection of blood specimens by veni-puncture

Numbering Systems

A numbering system can also be applied.– Provides each policy with a unique identifier.– Easier to file…has numerical order.

Numerical Filing System - Step 1

Establish major categories - Big Rocks– Make sure the categories make sense to staff.– Suggestions

• Board of Health……………………1000

• Governance………………………...2000

• Administration……………………..3000

• Emergency Response………………4000

• Occupational Health and Safety……5000

• Facilities Maintenance……………...6000


Sub-headings - Smaller Stones– Ex: Occupational Health and Safety…..5000

• Blood-borne Pathogens Policies……………5100

• TB Control and Prevention Plan……………5200

• Material Safety Plan………………………...5300

• Ergonomics Control Plan…………………..5400


Add groupings where needed.– Ex: Blood-borne pathogens………….5100

• Clinical applications………………………5110

• Laboratory applications…………………...5130

• Community Services applications………...5160

Numerical Filing System Step 4

File by title….the sand– Ex:

• Category: Occupational Health & Safety…..5000– Sub-heading: Blood-borne pathogens…………...5100

• Grouping: Laboratory……………………….5130

• Title: Collection of blood specimens by veni-puncture……………………………………...5131

Alpha-numeric System

Categorizes policies as discussed earlier and then numbers each policy within each category.

Alpha-numeric SystemStep 1

Establish major categories – Abbreviate each category.– Suggestions

• Board of Health…………………………BOH

• Governance……………………………..GOV

• Administration………………………….ADM

• Emergency Response……………………...ER

• Occupational Health and Safety…………OCH

• Facilities Maintenance…………………….FM


Assign each letter in the alphabet a range of numbers.

A 0 – 99 J 900 – 999 S 1800 – 1899B 100 – 199 K 1000 – 1099 T 1900 – 1999C 200 – 299 L 1100 – 1199 U 2000 – 2099D 300 – 399 M 1200 – 1299 V 2100 – 2199E 400 – 499 N 1300 – 1399 W 2200 – 2299F 500 – 599 O 1400 – 1499 X 2300 – 2399G 600 – 699 P 1500 – 1599 Y 2400 – 2499H 700 – 799 Q 1600 – 1699 Z 2500 - 2599I 800 – 899 R 1700 – 1799


A policy in the Occupational Health and Safety Section titled “Completing an Incident Report” may be assigned a policy number such as OCH-205 where OCH represents the category and 205 indicates it starts with C.

Alpha-numeric System

The number spread can be increased to 1000 if the agency has more policies.

Be sure to include enough numbers to start with in order to avoid having to renumber policies later.

Disposition of Superseded Policies

Retain an original of outdated policies in the Agency

Retention of old policies should be in accordance with recommendations in the LHD Record Retention and Disposition Schedule

In order to supply documentation of standard of care in litigation situations agency policy may require archiving or retaining a microfilm copy despite the retention schedule

Policy Management and Storage Knowing what you have and where it is.

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