POLICY AND PROCEDURES PROCESS
I. SUMMARY OF DHMH’s Policy and Procedures Process
A. Proposing Unit evaluates need for policy versus other guidance document type.
B. Concept approval for policy by relevant Deputy Secretary. Also consider Procedure to accompany Policy, if needed.
C. Proposing Unit meets with the DHMH Policy Administrator to mold intended policy content into an acceptable format, style, and utility.
D. Proposing Unit or Units develop draft policy document. OAG/OIG assist.
E. Proposing Unit research web links, references, codes, regulations, laws for final versions.
F. Prepare final draft submission for processing. Collaborate with Policy Administrator to provide other info, authorities, references, links,
G. Policy Administrator puts document in final format- prepares policy review packet and enters policy into tracking database.
H. Policy Administrator transmits packet to:
(1) Unit Chief/Program Director for unit sign offs and content approval;
(2) OAG for review for legal sufficiency;
(3) If applicable, all Program Directors of affected agencies for approval;
(4) Deputy Secretary of Proposing Unit for review and sign off.
I. Policy Administrator and/or Proposing Unit makes any agreed upon changes and returns to for sign offs if changes are substantive.
J. Policy Administrator forwards for Secretary’s signature.
K. Final electronic copy is updated with electronic signature - send to Lisa Ellis for this - and forwarded to web team.
L. Policy Administrator proofreads Intranet copy and distributes hard copies to those units not on intranet.
M. Policy Administrator files copy of Policy in Policy binder, in “POLICIES IN EFFECT' folder on shared drive.
N. Policy tracking database is updated throughout process.
II. GENERAL INFORMATION RE: DEVELOPMENT OF POLICIES/PROCEDURES.
A. The Secretary is responsible for the operation of the Department. DHMH policies and procedures are established under the authority of the Secretary to promote the orderly and efficient administration of the Department. DHMH policies and procedures are tools for employees and supervisors to use to obtain the Department's desired results.
B. Unlike laws and regulations, DHMH policies and procedures do not require legislative review. Unlike guidelines, protocols or standards, DHMH policies and procedures require the signature of approval of the Secretary, and may be applicable to any or all DHMH programs, employees, agents, grantees, contractors, etc. In recognition of the need for flexibility and accommodation of extenuating circumstances, individuals or DHMH components may request a waiver from a policy or procedure.
C. DHMH policies and procedures are to be user-friendly, written in plain English, and contain only minimum essential technical, medical, legal or scientific terminology. Older policies are to be screened and revised to comply with this requirement. Whenever legal, scientific or technical terminology is required, a plain-English paraphrase will also be provided.
D. The Program Director of the DHMH unit primarily responsible for the subject of the policy is also responsible for developing the draft policy/ procedure document and for submitting it to the Policy Administrator in both paper and electronic format.
E. When a Program Director has determined that a new policy is needed, he/she will first prepare and submit a Proposal of Policy Development (POPD) to the applicable Deputy Secretary or the Chief of Staff for approval.
F. After the Proposal of Policy Development has been approved, a preliminary draft copy of the proposed policy / procedure will be submitted by the initiating unit to the Policy Administrator who will assign a policy number, enter the policy into the index database and the policy status listing, and review the preliminary draft document.
G. After initial review, the Policy Administrator will recommend changes on a mark-up copy of the draft policy/procedure, returning it to the initiating unit for review. The responsible unit representative and the Policy Administrator will work collaboratively to facilitate and expedite policy development. Once agreement has been reached on the content and format of the policy/procedure, the Policy Administrator will place the draft document in a policy review folder with the support documentation to begin the review and approval process.
H. The responsible unit will provide the necessary policy research including all relevant hypertext links and reference citations, especially the relevant Annotated Code and COMAR links.
I. In developing a DHMH policy, consideration should be given to comparable policies in other Maryland agencies, other states, or other government units. A search of the Maryland Annotated Code, COMAR, and other internet resources would typically be accomplished during the development stage.
J. Federal, State and Local Authority
(1) Because a significant portion of DHMH activity includes management and operation of Federal programs, the Department and its employees are required to comply with Federal guidelines. Except where State, local or DHMH guidelines are stricter, more inclusive, or specifically override Federal guidelines, employees are expected to defer to and comply with State or Federal program requirements.
(2) DHMH policies are not required if the Department’s position is in agreement with a State or Federal policy, but policies may be developed to supplement, augment, or implement State or Federal guidelines when significant issues need to be addressed. If conflicts are noted, they are to be brought to the attention of the responsible unit and the Policy Administrator.
(3) EXCEPTIONS: All directives are subject to ongoing revision, so if and when conflicts or discrepancies are noted, consideration will generally be weighted in favor of the one that is most current or to the higher level of authority. In either case, however, exceptions to the general rule may be called for by the responsible Program Director
K. Legal Review
(1) Since there is a need to assure that the rights of the citizens of Maryland are safeguarded; that the Department and its employees are protected; and, that inadvertent conflicts with the law, COMAR, or other directives are avoided, all DHMH policies and procedures are to be developed in consultation with staff of the Office of the Attorney General.
(2) After a draft policy has been developed, a copy will be submitted to the OAG for review for legal sufficiency, usually before review and comments by affected Program Directors, unless the attorney requests otherwise. Generally, the staff attorney that is assigned responsibility for the unit developing the policy will also be responsible for signing off on the policy.
(3) During the review process by affected program directors and deputy secretaries, if legal questions are raised, the questions and/or the policy will be referred back to the reviewing attorney for resolution before proceeding to the next review authority. The reviewing attorney will be provided update versions of the policy and may suggest changes throughout the review process.
III. Policies and procedures - Numbering Protocol
New policy numbers consist of three sets of two digit numbers separated by periods, as follows:
A. The first set of numbers indicates the Deputy Secretary at:
01-Executive Office
02-Operations
03-Public Health, and
04-Medical Care Programs
B. The second pair of digits refers to the Office, Program, or Administration. This results in similar subjects being grouped together.
C. The third set of numbers is a sequential identifier, to differentiate policies within an administration.
D. Procedures have an additional period, letter “P”, and a sequential procedure number following the relevant policy number (xx.xx.xx.P1, etc.)
IV. POLICY — FORMATTING
A. General.
(1) Use 8 ½” x 11” paper, portrait view, with .5’ margins on top/ bottom, and 1” on left /right margins.
(2) The first page will include a standard policy header and footer, the latter of which may later be omitted in some electronic versions.
(3) On subsequent pages, the format for policies will include a standard header and footer on each page. These may be omitted in electronic versions.
Header Sample:
DHMH POLICY (Number)
Cross-Reference: Deputy Secretariat – Program
(Underline) __________________________
Footer: Sample:
Underline)_____________________________
Supersedes DHMH ...
DHMH (policy number) version date) Page ___ of ___.
B. Style Standards:
(1) Fonts – The standard font will be Arial 11-point-regular, with variations used by the Policy Administrator for emphasis and convenience, as needed.
(2) Style standards do not apply to addenda and attachments.
(3) All policies must contain the following sections:
(a) Executive Summary – Usually written last, this is a concise but general synopsis of the contents of the background and policy statement sections. All significant issues addressed in the policy are to be mentioned here, but also need to be addressed in detail in the Policy Statements section. [Text Format].
(b) Background –This is the history of the policy, to include mention of the DHMH policy being superseded, if applicable. Federal law and the Maryland Annotated Code, COMAR, Executive Orders and other applicable State agency directives are to be acknowledged. When updating a policy, the Background section should also state what is different in this policy version from earlier versions. [Text Format]
(c) Policy Statements - An organized, hierarchic listing of definitions, roles and responsibilities, principles, instructions, processes, considerations, standards, or other components of a plan to deal with the issue. [Outline Format]
(d) References - A bulleted, alphabetical listing of laws, COMAR, publications, and information resources from which the policy is derived, or that are cited in the policy, with brief descriptions. Hypertext links to online references are to be included whenever available.
(e) (Optional) Addenda, Exhibits, Appendix, etc.
(i) Essential supplementary data, forms, tables, listings, spreadsheets, letters and other documents which support the policy statements and which are placed at the end to maintain the continuity of the policy statements.
(ii) Other directives, laws, regulations, glossaries, dictionaries, etc. are not to be included in text as part of the policy, but may be incorporated by reference, and electronically connected by hypertext links.
(4) Content and Vocabulary
(a) To the extent possible, DHMH policies are to be written in plain English, with minimal legal, medical, scientific, technical, or foreign expressions.
(b) Whenever legal, scientific or technical terminology is essential, a plain-English paraphrase will be provided.
(c) Both vocabulary and word meanings are to be consistent with other DHMH policies, unless a special definition is needed and a new meaning is emphasized.
(d) Common acronyms (such as DHMH) may be used for brevity purposes, if first printed in full, and if not used repeatedly with other acronyms.
(e) Policy titles, especially, are to be succinct and descriptive, clearly indicating the explicit subject and scope of the policy at a glance, without elaborate and detailed delineation or qualification.
(g) In determining the level of detail of a policy or procedure, consideration must be given to which employees will be the end-users, their expected level of expertise with the subject matter, and what they will need to know to carry out the policy. Detailed, technical, or complicated instructions may better be conveyed through non-policy directives such as protocols, manuals, etc.
(h) Procedures, rather than policies, are to be used to provide detailed interaction.
(i) Terms that have special meanings are to be defined in Section III-A DEFINITIONS, but only include essential terms.
(j) Definitions will be arranged in alphabetical order.
V. PROCEDURES — FORMATTING
A. Procedures are to be formatted to optimize the use of electronic/online version while also providing convenience and organization to the printed versions. Since converting word-processor documents to a web-compatible format currently may result in some distortion or loss of formatting, care must be taken to assure the integrity of both views of the procedure, so that the content is consistent, if not the exact same appearance. It is also possible that online appearance of a document may vary from one computer to the next, depending on the setup of the software, therefore, these formatting standards apply to the MS-WORD application and printouts, as follows:
(1) Use 8 ½” x 11” paper, portrait view, with .5’ margins on top/ bottom, and 1” on left /right margins.
(2) On subsequent pages, the format for procedures will include a standard header and footer on each page. These may be omitted in electronic versions.
(a) Header Sample:
DHMH PROCEDURE (Number) TITLE
Cross-Reference: Deputy Secretariat – Program
(Underline) __________________________
(b) Footer Sample:
Underline)_____________________________
Supersedes DHMH
DHMH (procedure number) version date) Page ___ of ___.
B. Style Standards: The standard font used will be Arial 11-point regular.
C. Required Sections
(1) All procedures will contain the following two sections formatted in two columns, like a script:
(2) First Column, ACTOR, person responsible for the action to be taken.
(3) Second Column, ACTION STEPS, the act to be performed by the responsible person/administration. (Text)
(a) Each step is in chronological sequence.
(b) A new sequential item number is listed whenever a different actor performs the next action required.
VI. PROCESSING
A. Review and Approval Process
(1) When a determination is made that a policy or procedure needs to be developed for the Department, the responsible unit shall submit a Proposal of Policy Development (POPD) through the appropriate Deputy Secretary or the Chief of Staff for approval.
(2) Once approval of the POPD is received, the Policy / Procedure Review Authorities will be selected, to consist of the initiating unit’s Program Director, the Directors of other affected Administrations/ Programs, the Deputy Secretaries and Chief of Staff, and the DHMH-Office of the Attorney General. Policies /procedures which affect facilities or Local Health Departments will include the relevant Administration and, at the request of the Deputy Secretary for Public Health, select facility directors or Health Officers. Other experts, specialists, or authorities may also be included in the final review process at the request of the Policy Administrator, the initiating unit, or other review authority, but their approval is not necessarily required.
(3) The Policy Review and Approval Form (green), a “mark up” copy of the most current draft, and the signature copy of the policy will be included in the right pocket of the folder. The left pocket will include all significant interim revisions of the policy, with markups, review comments and responses, references, attachments, etc. A copy of the policy on diskette will also be included.
B. Modified or Expedited Review and Approval Processes
(1) E-Mail Review-To minimize review time at the Program Director level, copies of the latest draft will be e-mailed to Directors of all programs affected by the policy with a request for comments and suggestions to be submitted generally within a week, with absence of response/comments indicating approval. The Policy Administrator and program representative(s) will work collaboratively to address issues and modify the draft where needed. The comments will be compiled and presented to the reviewing attorney and the Deputy Secretaries as part of the review package.
(2) Committee Review- For policies dealing with issues under the purview of DHMH committees comprised of management of affected programs such as the Health Information Coordinating Committee (HICC), the draft policy may be distributed to committee members for their review and comments. The issues and comments of reviewers are to be addressed initiating unit which will modify the draft as needed and resubmit the revision to the committee for their vote of approval. Comments will be compiled for the reviewing attorney and Deputy Secretaries’ review.
(3) Routine Update Review- For policies that are being revised but don’t include major differences from the current policy, review/approval requirements shall be limited to the responsible program director, attorney, and Deputy Secretary before being submitted to the Secretary for signing.
(4) Representative Review- With the approval of the Deputy Secretary for Public Health Services, instead of all program directors, facilities, or Local Health Officers reviewing a policy, select representatives may be chosen to identify and comment on the relevant issues.
(5) Concurrent Review- In instances where review is expected to take significant time and where the supplemental information in the review packet is important for decision-making, a number of duplicate review packets may be prepared and circulated for comments. All reviewers’ comments and signatures are to be consolidated into one final review packet for the Secretary’s signature.
C. Review Comments and the Revision Process
(1) The initiating unit representative and the Policy Administrator will work collaboratively in refining the draft policy /procedure to reach a consensus on the edits and changes.
(2) The Policy Administrator will forward substantive comments and issues raised by reviewing authorities to the initiating unit and/ or the reviewing attorney who shall respond to the comments in writing or e-mail, and a copy of the responses will be included in the policy review folder.
(3) If substantive changes are made to the policy after partial approval, an information copy of the resulting version will be e-mailed to the review authorities that have already signed off to give them an opportunity to comment on the changes.
(4) The Review and Approval Routing Sheet will accompany the revised policy / procedure for the Secretary’s signature.
(5) To facilitate processing, the Policy Administrator may make non-substantive, grammatical, or organizational changes to the policy, as needed, at any stage of policy development.
D. Tracking System
(1) The Policy Administrator, in order to monitor the location and status of each policy folder particularly during the review process, will use an internal tracking system that indicates location and past-due responses.
(2) Current Policy List
(a) A list of current DHMH policies will be found on the DHMH website Policy Page.
(b) A cross-reference list of old policy numbers to new policy numbers will be maintained by the Policy Administrator.
E. Distribution
(1) Electronic Copy
(a) After the Secretary has signed the original policy / procedure, the final version includes the Secretary's electronic signature.
(b) The policy/procedure will be converted to Adobe PDF, proofread, then placed on the DHMH Policy Page.
(c) Once t he policy has been placed on the policy web page, an e-mail notification will be sent to all applicable DHMH program directors, health officers, facility directors, board administrators, etc. with a hypertext link to the online policy and an attached copy of the final policy. Directors/ health officers will distribute the policies to their staff, as appropriate.
(d) Shared Drive Copy. An MS-Word version of all new or updated policies and procedures will be placed in the “New Policies” folder on the DHMH network Shared “S” Drive. Documents will be password protected to prevent unauthorized changes.
(2) Paper (Hard) Copies
(a) A paper copy of the final policy shall be distributed by the Policy Administrator to the following units:
(i) The DHMH Web Team;
(ii) The initiating unit;
(iii) Units lacking access to the internet.
(b) One hardcopy DHMH Policy Manual is maintained by the Policy Administrator.
(c) The original policy packet with Review/Authorization sign off sheet, and documentation will be kept as a permanent record by the Policy Administrator, including the official, signed copy of the policy.
