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Plans - Management Plans vs. Policies/Procedures

How do management plans differ from policies and procedures?

Any examples are for illustrative purposes only.

Management plans are not operational policies but provide a high-level framework for managing the environment of care (the physical environment). In other words, management plans should be a roadmap/outline to describe how the standards apply to the organization, and then describe how the organization will comply with the applicable standards. 

Management plans should include, at a minimum:
  • All facilities, spaces, equipment, people
  • How risk is managed through planning, implementing, evaluating and evaluation of results
  • Specific risks and unique conditions
  • Scope, objectives, staff responsibilities and time frame for identified activities
  • How leased spaces are addressed if care, treatment and services are conducted in those spaces
These are used as a guide to maintain ongoing environment of care standards compliance through meetings, reporting, data collection, communications, so that at the end of a 12-month period, the environment of care program can be effectively evaluated. Therefore, environment of care management plans are required be reviewed annually (EC.04.01.01 EP 15).  Data collected is analyzed in order to identify opportunities for improvement and to resolve issues.

Policies are a set of rules around which work is accomplished.  Plans provide the overview for the work done considering the policy.  

For example, some organizations create a single, overarching policy to provide authority for and enforcement of the management plans.  These management plans are dynamic documents which can be modified more readily than a policy.  Additionally, management plans may reference several policies, procedures or other documents.  Some organizations choose to have all plans in policy form.  It is up to the organization to determine the best structure and format of their management plans to address their individual needs and circumstances.

Reference: EC.01.01.01 
Manual: Hospital and Hospital Clinics
Chapter: Environment of Care EC
First published date: April 11, 2016 This Standards FAQ was first published on this date.
This page was last updated on October 26, 2021

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