How to run a policy review cycle in a general practice

Last checked 2026-10-13 · Original practical information

A policy review cycle works best when it is part of the practice's normal work. An annual folder clean-up can make documents look current without answering the questions that matter: does the instruction match what staff actually do, who approved it, and can the next person find the current version? This guide sets out an original workflow for a practice manager to adapt. It does not prescribe a universal review interval or establish that a practice meets accreditation requirements.

Start with an index you can trust

Before setting dates, list the documents that staff are expected to use. Give each one a stable identifier, a useful title, a category, an owner, the current approved version, its approval date and its next review date. Separate a policy that states the practice's position from a procedure that explains the steps. A single document can contain both, but the title should tell a staff member what problem it helps them solve.

Include the location of supporting material, such as a form or a supplier instruction. Record the source and edition separately from your local version. A document can be based on a published source while containing arrangements that only apply at your practice. Keep superseded versions as history, with a clear current version, rather than leaving several almost identical files beside one another.

Give one person responsibility for each review

Choose the person who can investigate the process and organise the review, rather than assigning everything to the practice manager by default. A reception lead might coordinate an administrative procedure; the person accountable for a clinical process should decide its clinical wording. The reviewer and final approver can be different people. Record both roles so a draft does not become approved simply because somebody edited it.

Ask the owner to nominate who else needs to be consulted. A good review might involve the people who use the procedure, the person maintaining the relevant system, and someone who can check the practice's legal or professional obligations. Do not assume that a publisher's new edition means the practice should replace its own wording without discussion.

Set a schedule that reflects consequences

There is no useful single date for every document. Decide review intervals locally, considering how often the process changes and what could happen if the instruction is wrong. Keep the rationale short. For example, a procedure affected by frequent software changes may need a different schedule from a stable administrative arrangement. Confirm any externally required review frequency with the applicable authority or professional adviser.

Add event-based review triggers alongside the calendar date: a significant complaint, a change in equipment, a new service, an incident, a privacy concern, or a change in official guidance. A future due date should never prevent an earlier review when something important has changed. Spread planned reviews through the year so the team has time to do them properly.

Review the practice, then review the wording

Read the current procedure with somebody who uses it. Walk through a fictional example and ask where a new staff member would pause. Check that named roles exist, links open, forms are available, and escalation arrangements are understood. Ask whether an instruction describes the real process or an ideal process the practice has never introduced.

Record the changes you propose and why. Keep useful local details such as where a form is stored, which role receives an escalation, or how work is handed over. Mark any uncertainty for the responsible person to resolve. Avoid filling a gap with invented timings, contact details or clinical instructions. A draft with a visible unresolved question is safer than an apparently complete document that nobody has verified.

Approve a specific version

Save the final draft before asking for approval. The approver should see the exact wording that will become current, including attachments and local sections. Record the decision, the approver, the date and the version. If the wording changes after approval, treat that as a further revision requiring the appropriate decision, rather than quietly overwriting the approved record.

A review can also conclude that no change is needed. Record what was checked and the next review date; do not manufacture a wording change just to demonstrate activity. If a document is withdrawn, record why and direct staff to the replacement. Remove withdrawn instructions from normal search results while retaining their history for authorised review.

Help staff use the change

An updated manual needs a communication plan. Identify the staff roles affected and explain the practical difference. A small wording correction may need a short note; a new workflow may need a demonstration and questions. Ask for acknowledgement of the exact approved version where that is appropriate. Acknowledgement records receipt or reading, not proof that someone can perform a task safely.

Schedule a short follow-up after a meaningful change. Ask staff whether they can find the instruction and whether it works at the desk. Use their feedback to correct confusing language. Keep patient details out of a general policy register: link authorised people to the appropriate secure record instead of copying a case into widely accessible notes.

Make the monthly review small and predictable

At a regular team or management meeting, look at reviews due soon, overdue reviews, drafts waiting for decisions and actions arising from feedback. Deal with blocked work explicitly: identify the missing input, the person who will obtain it and a realistic next date. Moving an overdue date forward without recording what happened hides the problem rather than solving it.

Export the document index and approval history when preparing evidence, then sample a few records back to their original wording. Formal accreditation is assessed by an independent accreditation agency; an organised index supports that conversation but does not determine the outcome. Begin with five frequently used policies, improve the workflow, and expand the schedule once the team can maintain it consistently.

Sources

• RACGP — Accreditation
• OAIC — Guide to health privacy

See how this works in the practice hub · Download the original policy review schedule