top of page

Understanding the difference between policies, procedures, protocols, and guidance, PPPGs

It is now over two years since I wrote the blog on ‘understanding the difference between policies, procedures, protocols, and guidance, PPPGs’. Our website statistics tell me that this blog has been the subject of hundreds of hits. Given the level of interest I thought I would make it available to you again.

All staff in social care services follow policies and procedures in the course of their work so it is important that they have a clear understanding of what they actually mean. I have found in my quality assurance career that there is often confusion surrounding the difference between a policy and procedure, let alone guidance and protocols.

In this week’s blog I thought I would try to help by unravelling some of the mystery in the understanding of the terms. At Bettal Quality Consultancy we have recently been commissioned by an organisation in Ireland to produce a quality management system that complies with Irelands Health Services Executive requirements for the production of policies, procedures, protocols and guidance, PPPGs. This is required of all clinical and non-clinical services. I must say at the outset that whilst the approach is very demanding, I do think it will help to improve quality of Social Care Services.

Defining policies procedures protocols and guidance

What is a policy

A policy clearly indicates the position and values of the organisation on a given subject. For example, a policy on infection control will set out how it intends to comply with national standards and best practice. It is a written operational statement of intent and explains the organisations stand on a subject and why there is a rule about it. (HIQA, 2008).

A policy is a means of guiding an organisation to a desired outcome.

What is a procedure

A procedure is a written set of instructions that describe the approved and recommended steps of a particular act or sequence of events (HIQA, 2008). Procedures supplement polices and describe how the policy will be implemented and met.

For example, a procedure on infection control will provide step by step instructions on how to control infection.

What is a protocol

A protocol is a written plan that specifies procedures to be followed in defined situations: A protocol represents a standard of care that describes an intervention or set of interventions. Protocols are more explicit and specific in their detail than guidelines; in that they specify who does ‘what’, ‘when’ and ‘how’ (HSE, 2012).

What is a guideline

A guideline is defined as a principle or criterion that guides or directs action. Guideline development emphasises using clear evidence from the existing literature, rather than expert opinion alone (HSE, 2011).

Doing the right thing consistently to ensure the best possible outcomes for patients and service users, satisfaction for all customers, retention of talented staff and a good financial performance. (Leahy, 1998).

The importance of policies and procedures in a Social Care Service

Policies and procedures are designed to influence and determine all major decisions and actions within a social care service, and all activities take place within the boundaries set by them. Procedures are the specific methods employed to express policies in action in day-to-day operations of the service. Together, policies and procedures ensure that a point of view held by the governing body of an organization (a policy), is translated into steps that result in an outcome compatible with that view.

Policies, procedures, and inspection

All social care services in the UK are required to comply with national standards. Inspectors will in the course of an inspection review a social care services policies and procedures to ensure that national standards are being met. It is essential then that every service has in place a quality management system that meets the required standards and is monitored and audited to ensure compliance.

Why not visit our website at, or give Stuart a ring on 0169773284 to learn about how the Bettal Quality Consultancy CQC Compliant Quality Management System can support your service.


A clear understanding of policies, procedures, protocols, and guidance PPPGs, are important to social care staff in that they underpin the delivery of care services. There is a clear distinction between a policy which is an organisations statement of intent and a procedure that is designed to implement the policy through work instructions to staff. A review of policies and procedures is central to the role of inspectors to ensure they are being followed by staff of a service, and that they comply with CQC Fundamental Standards, KLOES and best practice.

I trust the content of this week’s blog goes someway to a better understanding of policies and procedures.

Albert Cook BA, MA & Fellow Charted Quality Institute Managing Director Bettal Quality Consultancy

1 view0 comments
bottom of page