How to Create Policies and Procedures

MCRSP Guidance

MCRSP does not provide organizations with sample policies and procedures.  Instead, it urges each organization to develop its own policies and procedures based on its own mission and vision. Please contact MCRSP staff who might be able to assist you in seeing policies and procedures that have been developed in other organizations.  However, we strongly urge you to develop your own, based on your actual operations.  The following can be a guide to you in developing these policies and procedures.

Policy and Procedure Development Toolkit
Introduction and Overview of Worksheets 


Policy and Procedures Manuals:

  • guide and protect the organization;
  • assure uniformity across the organization;
  • assure equal treatment of service recipients; and
  • are required by funders.

Benefits of Customized Policy and Procedures:

  • Provide details on how your organization is designed to operate and is a base line for quality improvement efforts when challenges are identified.
  • Management can assure consistency across departments, among staff and across service recipients.
  • Staff can assure consistency for service recipients.
  • Service recipients can expect consistency from staff, understand their rights and responsibilities and clearly understand consequences of their actions.

Differences Between Policy and Procedures:

Policies set some parameters for decision-making, but leave room for flexibility. They show the “why” behind an action.

Procedures, on the other hand, tell the “how.” Procedures provide step-by-step instructions for specific routine tasks. They should outline who is responsible for each task, what steps they need to take, who they need to report to, and so on. Certain procedures may even include a checklist or process steps to follow.

Good policies and procedures clearly identify: Who, What, When, Why, and How

  • Policies- often focus on what and why, can include who and when
  • Procedures- roadmap to get there, includes who, when (including time-frames) and how

Policies and Procedures should be clearly documented and easy to understand by individuals within and outside of the organization.

Policies and Procedures should be realistic given your organization’s resources.

Forms relevant to the policy and part of the procedure should be cited and attached.

Core Policy and Procedures Topics:

Policy and procedure manuals range from simple to complex, and can be from several pages to multiple volumes depending on the organization, their services and funding arrays.

Core topic areas will include:

  • Governance, including an Organizational Chart
  • Management and Staff
  • Services and Service Delivery
  • Records and Reporting
  • Fiscal and Financial Management - New Worksheet for Recovery Residences
  • Complaints and Grievances - Temporary Operating Procedures
  • Compliance with Federal, State, Local and Funding requirements (i.e. 42crf)
  • Certifications and Licenses
  • Code of Ethics
  • Non-Discrimination
Programs and Services:
  • Services and Supports - New Worksheet on Recovery Planning
  • Client Eligibility
  • Admissions and Discharges
  • Program Requirements - Temporary Operating Procedures for Use of Medications in Accredited Recovery Residences
  • Client Records and Reporting
  • Client Complaints and Grievances [MS1] [GS2] 

Each of these topic areas will often include subtopic and/or chapter areas.  As many of these core topic areas can and do impact on each other, organizations should develop a cross-referencing protocol at the beginning of their policy and procedure development process

How to Use the Policy and Procedures Development Worksheets

The purpose of these worksheets are to guide your organization in the development of core policies procedures and documents that:

  • Accurately reflect your organization mission, values, structure and services
  • Are understood and owned by all levels of your organization

Worksheets are arranged in the following sections:

  • Core Principles and Acceptable Evidence
  • Documentation Considerations for Policy, Procedures and Forms/Documents
  • Key Elements for written Policy, Procedures and Forms/Documents