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Revamping Your Organisational Policy Framework: Exploring Three Key Overhaul Options

Updated: Feb 22

This article discusses the dilemma of organisational policy framework overhauls and provides the pros and cons of three approaches to getting your policies up to speed. The goal is to ensure your organisation does not end up with generic policies and procedures that do not support and guide employees, resulting in a hot-mess of non-compliance.

Image: Two people sitting at a desk - the photo is from the shoulders down. They have paperwork on the desk and one person is holding a pen. They are probably reviewing their organisation's policies - or they should be! This image is sourced from Unsplash.


Organisational Policy Framework Overhauls

We know they need to be done, but no one that I know looks forward to it. However, when your industry is facing significant change and reform (such as Aged Care and Disability), and/or your organisation has experienced significant changes in functions, services and roles, it's no longer an option.

I have spent many hours over my career researching/developing policies, reviewing policies written by others and wrangling teams in organisations to review and agree on updated policies. I have also been responsible for developing policy frameworks.

What is a Policy Framework?

A policy framework is the umbrella or structure of an organisation's policies and procedures, including the style, tone, templates to be used, policy areas to be covered, policy ownership, and mechanisms for policy development, approval, implementation and review. Policy frameworks are essential for good organisational governance and should be in the skillset of a seasoned quality management professional.

But I digress - I was planning to talk about the situation where you know that you need wholesale change to your policy framework, or you are starting out with a new service or business and need to start from scratch.

There are only three routes that organisations usually take - 1. work it out and do it yourself via a team (or one unlucky individual), 2. purchase an off-the-shelf solution or 3. outsource the updates to an expert/s who coordinate the work, and collaborate with the teams involved to review and update the policy framework and policy content.

Let's discuss the pros and cons of each.

1. Do It Yourself

In this situation, you may not have the budget to pay for an expert to assist you, or you may be lucky enough to have the internal resources (i.e. people) to coordinate, research, collaborate and update your policies and the overall framework (lucky you!).


  • A tailored approach Your people know your organisation. The policies and associated content should have the look, feel and tone of your organisation and reflect your organisational culture and values. They also know their colleagues and have developed rapport so that they can work with them to update content and get consensus on key changes.

  • A professional development opportunity Despite the challenge of this kind of work, the experience for those involved is invaluable. This is a very good way for new and emerging quality and governance leaders to learn about many functions and areas of the organisation and understand how they fit (or should fit) together.

  • The policy framework can grow organically business development and growth Policies can be developed as new services or functions are developed in an organisation and roles and responsibilities assigned. This means policy framework development and review can become more of a business-as-usual and not seen as a separate 'thing' that needs to be done by someone else.

  • No extra budget required In-house resourcing means no additional cost to the organisation (or does it)?


  • It's bigger than any person's 'day-job'. If your organisation does not allow for extra resourcing and expects the work can be done as well as the usual "day job" of the individuals involved, the timeframe for completion will be hard to estimate. Even if you have someone who has a role focused on policy, it is unlikely that they cover all policies across the organisation. If there is a set timeframe (such as a new Aged Care Act coming into effect) the deadline can't be moved. In this scenario, if your organisation can demonstrate significant, steady progression and a prioritised, risk-rated approach to updating policy, this may not be an issue with the regulator, (at least for the first few months) but how will your Board feel about the delay? What have you promised? If you haven't considered this, the person or people you have assigned the task to are likely working an excessive number of hours to try and keep the work on track. This introduces the risk of burn-out and/or disengagement from the work that needs to occur.

  • Requires policy governance expertise Policy updates require knowledge and experience in what needs to be changed and why. Someone needs to look across all areas of the organisation to ensure the policies written or updated reflect all current requirements from a legislative perspective as well as meeting consistent written internal (organisational) communication expectations. There is also a need to ensure that policy is integrated across functions and service streams - for example there are not three versions of an incident management policy across three service streams. There may need to be three different procedures for incident reporting to reflect key differences in client/participant/consumer groups to capture differing regulatory needs, but the overall approach to incident management involving the customer should be consistent across the organisation. And finally, there will be at some point be differing views regarding policy content - whoever is coordinating the policy updates needs to bring people with various views and opinions together to reach a consensus. All of this is policy governance.

2. Off-the-shelf - the silver bullet solution

This is where an organisation may decide to purchase a package of written policies and procedures mapped to legislative and compliance requirements.


  • A quick start If you are developing a new service or starting a new business (such as being an NDIS or Aged Care community-based Provider), an off-the-shelf solution of policies, procedures and forms/templates may be a good solution for you. The reason I say this is because this type of solution will get you started and give you a good overview of the areas that you need to cover regarding policy and the general content that may be expected to be covered for an audit.

  • Helpful for gap-analysis For organisations who have existed for some time, purchasing an off-the-shelf package may assist you to conduct a quick gap analysis against what you have in place and perhaps offer you a faster way to address gaps in your policy areas that you have identified.

  • Updates provided when needed Some off-the-shelf solutions offer a subscription which provides regular updates, which assists organisations to ensure their policies remain current.

  • Fixed cost Off-the-shelf solutions are a one-off fixed cost and perhaps an annual subscription (with the promise of updates when there are changes in compliance obligations). This cost is easier to include in an operational budget.


  • There is no silver bullet. Sorry about that. An off-the-shelf solution will still require review, checking and tailoring to your organisation. The time and resource for this will depend on the quality of what has been purchased.

  • It is not a policy framework It's a suite or package of policies and procedures. The organisation still needs to determine policy ownership and establish mechanisms for policy development, implementation and review (at minimum).

  • Can create a false sense of security regarding compliance - Policies and procedures can stand up through an audit without any major nonconformance. This can create a false sense of security for organisations who purchase these items. However, in my work as an independent consultant conducting NDIS and aged care compliance reviews is that the gaps and inconsistencies in these generic policies are found during a review or investigation of a complaint or incident by the regulator, when they have not been tailored to the organisation and/or checked that they meet compliance requirements through internal audit processes by the organisation. Policies must consider a number of items collectively to meet compliance expectations. This includes the legislation, regulations (rules) and relevant regulator guidance material and interpret how the organisation needs to respond to ensure compliance. For those offering both NDIS and Aged Care services - this becomes even more complex.

  • Generic policy may create issues with lack of staff ownership and engagement When off-the-shelf solutions are not tailored to the organisation there is the risk of a lack of engagement of staff with their own policies and procedures. Teams may not refer to the policies and procedures for guidance as they do not offer guidance specific to their service needs, and some staff may be unaware of their existence as they have been discarded. If they are not tailored and reviewed by the organisation they do not reflect its tone, communication style or look and feel. They most likely also do not reflect what is actually happening, and may encourage the development of work arounds and informal, conflicting practices that is the exact opposite of what we want to achieve with good policy. (It is worth noting that a lack of embedding any policy - written by the organisation or not - through communication and education strategies can also result in employee disengagement).

  • Industry compliance requirements is just one aspect of organisational policy. Off-the-shelf solutions tend to focus on the compliance requirements of the industry in question (such as Aged Care, Retirement Living and Disability). However, there are other business compliance requirements needing policy that go beyond quality standards and industry legislation. Also, industry standards and compliance requirements can and will change. This is why it is never a good idea to build a policy framework around industry standards - the organisation's context is much broader than this.

  • Potential to limit organisational agility and growth Policy also provides an organisation with an opportunity to express and set its position on other issues relating to its mission and values, the services it provides and the people that work within it. Indeed, policy is an anchor for organisational culture. A generic approach can stifle the agility and growth of an organisation and foster a minimum compliance or 'tick-the-box' organisational culture.

  • Issues with consumer perception If your staff feel that the policies and procedures do not offer them with relevant support and guidance, what do consumers think? As we know, consumers are now more mobile with services and supports received - what do they think if they see the same content in policies relating to consumer engagement across each service that they interact with?

3. Engage an external expert

In this situation, you have the budget and motivation to hire someone a consultancy to help you coordinate the overhaul of your policies.


  • Access to skills and experience You have hired someone who has skills and experience in performing this type of work for other organisations. This means that you can rely on them to perform the work to the agreed timeframe, to provide up to date advice on policy content within their areas of expertise, and to implement strategies to collaborate with all relevant people within the organisation to get the work done. Otherwise they don't get paid!

  • Professional development opportunity for your team You may have team members who are developing their skills in policy development and review. This is an opportunity for them to hone their skills by working with the consultants so that in future you can update and develop new policies within your organisation without external assistance.

  • Retain focus on BAU Although the consultant will need to collaborate with various people to perform the work required to overhaul the policies, they will hold the responsibility for the overall coordination of the work (what I would call the project). This means that your teams can be focused on performing their day to day roles - this may reduce their stress and increase their motivation to engage with the work. They can and should contribute but are able to do so without "dropping the ball" on the critical aspects of their role.


  • External expertise may not cover all bases The skills and experience of the consultant/s engaged may not cover all of the policy areas that require updating. This is where the consultants you engage should be sourcing appropriate expertise or advising you of their limitations in their proposal for the work so that you can source the additional expertise you need elsewhere.

  • Retaining the organisation's voice There is always the risk that the consultants you engage want to take a "cookie-cutter" or generic approach to updating your policies as this saves them time. It is important to establish your expectations regarding tailoring the content and the documents to your organisation from the start. In some cases you may not have examples of written content to assist them to understand your organisation's style, or a style guide.. or you may want to refresh your approach. It is important to work all of this out in the scope of work for the project at the very beginning so that no-one is disappointed and your organisation gets the outcome that it needs.

  • Cost There is a cost in engaging a consultant, particularly if they will be developing the policy content tailored to your organisation as well as the policy framework itself. How much this will be depends on the size of the organisation, the maturity of the policy framework, the extent of the overhaul required and whether the organisation has any internal resources to support the work required. This needs to be carefully considered against the cost for alternative strategies outlined above, and the potential issues.

Despite all this, in the current economic climate you may have additional budget constraints.

Consider the following hybrid options to reduce costs:

  • Narrow the scope of work for the consultant to create a new policy framework and focusing on completing agreed high priority policy areas in the first stage, with the remainder to be picked up by the organisation in the second stage of the project.

  • Purchasing an off-the-shelf product that you have determined is the best fit and have the consultant help you to tailor it as a first stage and identify any new policies that you will need to develop internally in a second stage. This is similar to the above point but the consultant is not starting from scratch. I have found this works well with solutions that are templates with triggers for further tailored content to be added. It is much easier to adapt the style and then flesh out as needed with tailored content without having to rewrite complete documents.

  • Develop your own policy framework and engage the consultant to only develop high priority policy content that you have determined you do not have the time or in-house expertise.

  • Hire someone with relevant expertise on a fixed-term contract to complete the work required. This means that the person would be an employee for this period. This option should be discussed with your HR team.

  • If you have the sufficient expertise and time to research and update the policy content internally, don't engage external experts! Consider hiring additional high level administrative and project management support on a fixed-term contract to assist with the coordination and updating of the documents in a timely fashion.

How do you decide the best approach?

It depends on a few things - your budget, in-house expertise and availability, and your timeframe. I have provided three options with pros and cons for each. The reality is that you need to take one approach (or a hybrid or combination of approaches) to meet your organisational needs. The most important thing is to start. And if circumstances change, you can always change your approach.

How can I help?

I am always happy to be a sounding board to help you work out the best approach. You can use my free 30 minute remote (zoom or Teams) consultation booking or book in for a one hour remote mentoring session (price to be advised on enquiry). Contact me to discuss via my web page or LinkedIn.

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