MDH Policies - Summary of Policy Implementation Guidelines


For MDH’s purposes, a “policy” is considered an internal plan of action and/or decision-making to be used by  MDH employees when encountering certain issues or conditions that are the subject of the directive. A “procedure” is a step-by-step process of interaction between designated individuals (actors), for the purpose of carrying out a  MDH policy.

  • ​MDH policies and procedures are tools for employees to use to obtain the Department’s desired results, and are established under the authority of the Secretary, having undergone review and approval by the OAG, and officials of affected  MDH components. 
  • Unlike laws and regulations, s apply only to  MDH employees and do not require legislative review.
  • Unlike guidelines, protocols, and standards,  MDH policies and procedures require a signature of approval of the Secretary, and are mandatory for MDH employees. In recognition of extenuating circumstances, individuals or MDH components may request a waiver from a policy or procedure.
  • MDH policies and procedures are intended to be user-friendly, written in plain English and containing only minimum essential technical, medical, legal, or scientific terminology.


All MDH policies will follow a standard format, with the following sections:

  • EXECUTIVE SUMMARY- Written last, this is a concise but general condensation of the content of the policy statements, references, and attachments. All significant issues addressed by the policy are to be included. (Text Format)
  • BACKGROUND- The history of the policy, including mention of those MDH policies which are being superseded, the Annotated Code and COMAR authorities, and related publications or directives of other agencies. Mention should also be given to significant differences, changes or additions from earlier versions of the policy. (Text Format).
  • POLICY STATEMENTS - An organized, hierarchic listing of descriptions, instructions, processes, principles, considerations, responsibilities, or other components of a plan to deal with subject issues. (Outline format)
  • REFERENCES - A listing of all codes, publications, and information resources from which the policy is derived or which are cited in the policy. Hypertext links to online references are to be included whenever available.
  • ADDENDA, EXHIBITS, ATTACHMENTS- Tables, listings, databases, spreadsheets, definitions, and other guidelines which supplement the policy statements and are placed at the end for the purpose of continuity. NOTE: NO publications, regulations, or references are to be attached.
  • Other Sections- As required, with consent of P&P Administrator.


Policies are to be promulgated for ongoing issues of significant Departmental importance which require the approval authority of the Secretary to enact. Procedures are to be issued when a policy requires clarification or instruction for compliance. 

  • Policies and procedures are to be prepared and kept up to date by the units having control and authority over the subject matter, and in accordance with MDH policy guidelines.
  • Initiating units will work cooperatively with the  MDH P& P Administrator to prepare and update policies, to assure timely processing, and to facilitate approval by relevant officials.
  • ​Facility, Administration and Program Directors have authority to issue guidelines, protocols, and standards in lieu of policies for their areas of responsibility and/or for use by their unit’s staff, when policies are not required.

If you need more information, please contact Michele Phinney


410-767-6499...(Fax) 410-767-6483 or email