Administration and Leadership, Documentation & Patient Care Reporting, EMS Insider

Development and Revision of Company Policies

Congratulations! After months of waiting for a decision, you’ve been hired by an ambulance company. During orientation, your field training officer gives you your identification card, payroll information and your medical direction policies, and shows you around the building. 

After your first week of employment, your child gets very sick and you need to call out to take care of him. You call on the supervisor and she tells you that you’re on probation and aren’t entitled to time off, and by doing so you risk losing your job. 

Now what?

You try to research this policy but can’t find any of this information in the documentation you were given on your first day. The supervisor tells you there isn’t a written policy, but it’s been a long-standing practice at this agency. Can they enforce this unwritten practice?

Why Do We Need Policies?

Policies and procedures are the first line of defense against risk for any organization. If legal actions are taken against an agency due to incidents involving their employees, it’s extremely important to be able to show a policy is in place to provide direction, and that the employee was trained on the proper practices associated with the policy. 

Clearly written policies and procedures allow employees to understand their roles and responsibilities within predefined limits, and they allow management to guide operations without constant intervention. Constant management involvement results in increased operating expenses that detract from a company’s profitability.

In the case just described how do you show that an employee was trained on the policies your agency deploys? There are numerous software platforms available for purchase or subscription to that provide cloud-based policy training and content management services. Alternatively, there’s always the tried and true method of paper and an Excel spreadsheet that tracks who was issued policy information. 

Although this article touches upon some details for policy development, you must understand that litigation is fluid and may change, and it’s important to stay aware of these changes.

Where to start?

If you recognize that your agency needs to revise or add to your existing policy library, where do you start? First, a word of advice: don’t copy and paste another agency’s policies. Researching existing policies is helpful, but taking the content and simply changing the name of the ambulance company will not be helpful in court.

Start with the highest-liability, high-risk policies first, as these will be the most commonly defended in court. Such policies might be emergency vehicle operations, malpractice, sexual harassment and job abandonment. Once you know where to start with your policy manual, you can start thinking about how to structure your policies.

Policies and procedures should reflect and express an agency’s core values and priorities, and provide clear direction to ensure employees lawfully, effectively and ethically carry out their responsibilities. 

The purpose of a policy is to provide employees with the direction and guidance necessary to improve and develop as an individual, and to identify, correct and prevent misconduct. 

Ready to Write

There’s no fail-safe recipe for creating policies that will protect you against lawsuits. However, if you create and follow a structure for consistent policy development, you’ll be better protected and reduce your risk of liability. 

Agency polices can’t override state statutes and law, so be familiar with the laws in your state and jurisdictions. Accreditation standards are great to ensure your agency is following best practices. 

The Commission on Accreditation of Ambulance Services (CAAS) is a national, independent Commission that established a comprehensive series of standards for the ambulance service industry. Administrators should assign subject matter experts to write and/or review certain policies.

When writing, keep in mind that polices should specify the when, the where and the how, so be sure to ask the following:

  • What’s the reporting requirement? Example: Are cancelled with no patient contact calls for service documented?
  • What’s the supervision requirement? Example: Does a supervisor need to be present for all patient refusals?
  • What’s the training requirement? Example: Will sexual harassment training be covered biannually at a training day or in an online setting?

Communication & Dissemination

Dissemination should take place in the same manner for every policy (e.g, email, fax, cloud-based software, paper copies on a bulletin board, etc.). Employees should be expected to check this area on a routine basis for new or revised policies. 

Agencies should set a time frame where all employees are expected to read, review and sign acknowledging the policy. 

The employee doesn’t have to agree on the content of the policy but they do need to acknowledge its existence. Any clarifications should be done through a supervisor. 

If clarification is needed on a policy, documented remediation starts with the employees’ direct supervisor. Documentation is important to show that the employer properly trained the employee. 

If additional remediation is required, the employee should then meet with a member of administration to discuss the uncertainties. Again, this meeting should be documented fully with all points of discussion. 

There are times that members of administration should meet with all employees to discuss the development or promulgation of a new policy. In this case, questions and clarification can be provided to the whole team, rather than one-on-one.

Making Changes

Keep your audience in mind. Although you may understand what the policy says, are you getting the same questions repeatedly from different employees? If so, there may need to be a revision to that policy with more clarifying statements or updated language. Any revision should be properly documented and all previous editions should be retained permanently. 

If discovery is requested from a legal entity, a policy is requested from an incident that took place 5 years ago, and you revised that policy twice since then, how can you prove what the policy was at the time? 

Don’t rely on the other party to provide this information; be prepared and retain all previous editions of your policies. To keep from falling behind in best practices, set a date to review policies and make revisions as necessary.


Our original scenario outlined an employee wanting to use a sick day, but an unwritten agency practice doesn’t allow days off while the employee is on probation. 

The policy has been enforced in the company for as long as any current employee can recall, and there’s been discipline in the past for violation. 

If brought to court, there are numerous issues regarding the disposition of the case such as: Where are employees trained on this policy, are new employees told about this policy, when did the policy become “rule,” and what defines a probationary period?

Affirmations and defenses for this scenario are plentiful, but very difficult to prove on the plaintiff’s part. Although there’s no solid rule about what a policy should contain, you should follow the above guidance and framework to limit the exposure of lawsuits you and your agency may encounter. 


1. 42 U.S.C. §1983

2. Oklahoma City v. Tuttle, 471 U.S. 808, 105 S.Ct. 2427 (1985).

3. City of Canton, Ohio v. Harris (489 U.S. 378 1989).

4. Callahan M. Deliberate indifference: The standard for municipal and supervisory liability. FBI Law Enforcement Bulletin. 1990;59(10):27–32.

5. Brown v. Commonwealth of Pennsylvania Department of Health Emergency Medical Services Training Institute, 318 F.3d 473 (3d Cir. 2003).

6. Monell v. Dept of Soc. Svcs., 436 U.S. 658, 701 (1978).