Policy and Procedure Development Policy - Risk Management

Policies and procedures are the frameworks that organizations use to manage risk. They guide how to identify, assess, and respond to risks. They also establish a process for monitoring and reviewing risks on an ongoing basis.


Businesses will develop and maintain policies and procedures that outline and guide business practices at Business using the procedures defined in this document. This policy will cover the processes for creating new policies, revising existing policies, removing policies, and the regular review of policies. A designee will serve as the Policy Coordinator and be responsible for the storage of original documents (electronic and/or paper) and tracking the process for maintaining and regularly reviewing policies.

Policies will be written using a common format, filed, indexed, and distributed consistently to ensure workforce members have access to current policies. Policies shall be reviewed at least annually or when any major systems or business change occurs. Also, policies shall be revised as necessary, to comply with regulatory or accrediting body standards changes.


If a Business workforce member or Business committee determines the need for a new policy and/or procedure, they shall document the need for the new policy and/or procedure. The submitter(s) should make every effort to determine if the topic is covered by the existing policy and/or procedure. The proposal should then be forwarded to the supervisor for the area the policy affects. Business-wide policies should be forwarded to the Policy and Procedure Coordinator. The supervisor will review the proposal and either refer it to the management team or appropriate committee for additional review or return it to the submitter for changes.

A policy will be approved with the date and signature of the appropriate Manager(s) and/or committee chair. Once a policy has been approved it shall be formatted in the approved layout attached below. The Policy and Procedure Coordinator will give the policy and/or procedure to the coordinator who is responsible for overseeing the review and revision of the policy.

Policies go into effect no earlier than fifteen (15) calendar days from the date of management approval/signature to allow for adequate workforce training time.

A copy of the policy will be centrally stored as designated by Business. The policy and procedure storage location will be maintained by the Policy Coordinator. The supervisor of the area to which the policy and/or procedure applies will maintain a copy of the signed policy. The Policy Coordinator will also maintain a copy of the document.

Policies shall be reviewed annually or when a major system or business changes occur by the policy coordinator and revised as needed.

  • The Policy Coordinator will notify the supervisor or if the policy is a Business-wide policy, Business, or designee that the policy is scheduled for review which will coincide with the annual compliance audit.

  • It is the responsibility of the supervisor, Business, or designee to review and update the policy and/or procedure if necessary.

  • A select group of impacted workforce members shall be involved in the review and revision process to reasonably ensure the policy and/or procedure accurately matches current practice and appropriately addresses business and regulatory requirements.

  • If a workforce member notes a needed policy and/or procedure change before the regularly scheduled review, the workforce member shall notify the Policy Coordinator.

  • If a revision is warranted, the Policy Coordinator shall work with the appropriate manager or a Business designee to update the policy and/or procedure to reflect current practices and compliance with appropriate business practices and regulatory requirements.

  • Review and revision dates shall be noted in the policy document.

  • Policies and procedures are to be retained for a minimum of six years from the date the policy and/or procedure was last in effect.

Policies are to be distributed as follows:

  • Departmental policies are distributed by the supervisor to impacted workforce members.

  • Business-wide policies are distributed by the Policy Coordinator or other individuals designated by {Company Name} to impacted workforce members.

  • All policies are to be added to the Business’s internal website (Intranet) within five (5) working days of final approval.

  • Impacted workforce members shall be trained on new or revised policies and procedures within 30 days of the policy and/or procedure change or effective date of the new policy and/or procedure.

  • Workforce training shall be documented and retained for a minimum of six years.