WRITING STANDARD OPERATING PROCEDURES AND GUIDELINES

08/01/1999

WRITING STANDARD OPERATING PROCEDURES AND GUIDELINES

JOHN LEE COOK, JR.

The most visible part of life in any organ-ization is the daily, weekly, monthly, quarterly, and annual cycle of routines, procedures, reports, forms, and other recurrent tasks that have to be performed. The origin of such routines is often not known to participants, or sometimes even to senior management, but their existence lends structure, predictability, and concreteness to an otherwise vague and ambiguous organizational world. The systems and procedures thus serve a function quite similar to the formal structure: They make life predictable and, thereby, reduce ambiguity and anxiety.¹ Predictability is important in the fire service, especially when so much of what we do is totally unpredictable.

Nevertheless, we live in an era when the hierarchical organizational structure of many fire departments is being flattened, and chiefs who subscribe to the concepts of participative management and employee empowerment are replacing authoritarian fire chiefs. Therefore, it is not surprising to find that the traditional system of formal rules and guidelines that clearly establishes command and control is being challenged in many departments and is being dismantled in some cases. Likewise, small departments, which have historically operated without a formal system of rules and guidelines, are increasingly reluctant to adopt a formal system, the current wisdom being that formal policies and procedures increase liability and invite litigation.

What many people fail to understand, however, is that participative management does not mean permissive management, nor should the concept be used as an excuse for anarchy. Participative management environments, perhaps more so than others, must have an organizational culture and structure that encourage free thinking and involvement while at the same time preserving order. Otherwise chaos reigns. An effective set of rules and standard operating procedures (SOPs) can actually empower employees and managers by standardizing the routine, mundane tasks and allowing the members of an organization to focus on more critical areas of concern. Let`s examine why this is true.

First, a definition of terms used throughout this article is in order.

•General order: a written, numbered directive that changes, alters, or amends a department`s rules, regulations, policies, or standard operating procedures.

•Guideline: a statement of policy by a person or group having authority over an activity.

•Policy: a plan or course of action designed to influence and determine decisions, actions, and other matters. A policy`s basic purposes are to achieve consistency of action and to provide guidelines to be followed in performing the functions to which they apply.

•Procedure: a way of performing something and/or a set of established methods for conducting the affairs of the department. Procedures serve to implement policies by prescribing the course of action to be taken in the administration of these policies and indicate the chronological sequence of steps to be followed in observing established policies.

•Regulation: a principle, rule, or law designated to control or govern behavior.

•Rule: an authoritative direction for conduct or procedure.

•Standard operating procedure (SOP): an organizational directive that establishes a standard course of action (NFPA 1500, Standard on Fire Department Occupational Safety and Health).

WHY RULES AND PROCEDURES SHOULD BE PROMULGATED

There is an unlimited litany of excuses for not developing written rules and procedures or for not following them if you have them. If your department relies entirely on volunteers, you may be tempted to believe that you cannot tell volunteers what to do. If your department is small, you may think SOPs are something that only the big-city departments want or need. Or, maybe your department has had SOPs in the past that no one followed. None of these arguments are valid. Fires do not discriminate based on the employment status of a firefighter, geographical location, or the degree of commitment on the part of management. Fires do, however, discriminate between those who are prepared and those who are not.

Henri Fayol recognized the importance of control in managing an organization and said that control is necessary for verifying whether the actions of members are in accord with the organization`s adopted plans and underlying principles. Control involves monitoring for system weaknesses, human errors, and deviations from the assigned path. It allows discrepancies to be rectified and prevents their occurrence. Control touches on all aspects of an organization: people, actions, objects, and timing.²

Rules and procedures are a vital part of control and are an essential component of the management process. In any organization, control is necessary to minimize risk and ensure predictable outcomes during standard operations. Consistency of outcome and risk minimization are essential aspects of safe and efficient fireground operations. Fire suppression, after all, is a matter of life and death. When the outcome matters, three basic rules of risk management apply:

•Do not risk more than you can afford to lose.

•Do not risk a lot for a little.

•Consider the odds.³

Established procedures allow officers and firefighters to make decisions more rapidly and to build confidence, knowing that the results from one operation to the next will be uniform, thus enhancing efficiency. Rules give department members a greater sense of security. When there are rules, members know what treatment they can expect in a given situation. Officers are able to act with a greater degree of confidence in resolving problems with SOPs in place, since they have an objective basis on which to make and defend their decisions. When SOPs are the source of authority, an officer`s decision is less likely to be questioned.

WRITING RULES AND PROCEDURES

A number of principles apply when writing rules and procedures. First, rules and procedures should be appropriate for the department and should serve as a benchmark for performance and safety. SOPs should take into account the conditions that are present within the jurisdiction and the capabilities and limitations of the department. At the same time, it is not necessary to reinvent the wheel. If an SOP has worked well in another jurisdiction, there is no reason not to modify it to meet local conditions. Larger departments are an excellent resource, because they have more collective experience on a wide variety of problems. Most will gladly share their experiences.

Rules and SOPs must be in writing. Unwritten directives are difficult to learn, remember, and apply.⁴ Committing SOPs to writing also allows members to focus on critical rather than routine decisions. Unlike unwritten rules, written rules and procedures are not a secret. They are (should be) widely circulated and readily available to all department members. Written rules and procedures also provide structure and make a department more professional; they eliminate the game of trying to guess what will happen next. A formal system of rules and procedures helps reduce freelancing by individual members as well.

Standard operating procedures must be followed. Written rules and SOPs are effective only if they are used. An SOP that management does not enforce is not a true SOP and should be eliminated. Leaders define themselves by what they enforce [4]. Enforcement should be educational, providing the opportunity for positive rather than negative reinforcement. One method for reinforcing and institutionalizing rules and procedures is to include them as source material for promotional examinations. If an SOP is impossible to enforce, something has to change--the organization, its leadership, or the policy.

Knowing and following SOPs help individuals and groups develop a set of good work habits. Following SOPs can also protect against arbitrary action. Each of us is sensitive to differences, no matter how slight, in how we are treated in comparison with others. Following standard procedures with respect to every department member helps eliminate actual or perceived differences in treatment and the problems they can create. Not following SOPs, however, can have serious legal ramifications.

Rules and SOPs must be technically accurate, complete, and clear--not confusing. Policies should also aid rather than hinder decision making and should simplify rather than complicate matters. Written policies must not discourage an officer`s use of his own judgment when searching for a solution to a given problem. Nor should the officer use the department`s policies as an excuse for not taking action or approving a request. Policies must be dynamic. They must allow for change, depending on the circumstances. A policy is a means to an end, not an end in itself or an excuse for failure to take needed action.

Rules and procedures should be official. An official SOP is sanctioned by the department as demonstrated by a written general order from the fire chief establishing or enacting it. An SOP becomes official only after every member has been notified of it in writing. The fire station lawyers would argue that, if it is not in writing, it is not official and, therefore, may not necessarily apply in a given situation. It is easier to sanction or discipline a member of the department for violating a written rule. It is hard to demonstrate that an unwritten rule even exists. If it was that important, the argument goes, why was it not written down?

LITIGATION ISSUES

In our litigious age, some people conclude that the mere presence of written rules and procedures invites litigation and should, therefore, be avoided at all costs. Unfortunately, in the fire service, litigation is like risk--it is unavoidable. It is generally a question of when--not if--litigation will occur. The best thing a department can do is to be prepared when litigation does occur.

Standards are a valuable tool for organizational advancement, but adopting a standard leaves deep footprints. Make sure that your department is fully aware of a standard`s requirements. Failing to follow or use a standard does not make it go away. SOPs are not the law, nor do they take the place of law. They are evidence, however, and are information that can help a jury decide whether someone`s actions were reasonable. Where written standards do not exist, lawyers use expert witnesses to establish a standard of reasonable care and to define or describe accepted practice. The definition can be based on consensus standards, such as those promulgated by the NFPA, or on the expertise of an individual.⁵

Basing SOPs on nationally recognized standards and applicable state or local codes, ordinances, and regulations will make things easier for your department in the event of litigation. The broad base of acceptance a national standard enjoys, plus the length and complexity of the process involved in its development, will work in your department`s favor.<sup>6</sup> The prevailing expectation is that a knowledgeable, prudent person would follow the directives of an applicable national standard. Therefore, anyone attempting to find the department liable will have to focus on negligent action rather than on attacking the contents of the department`s SOPs. Obviously, this is not an airtight defense, because the provisions of a national standard are occasionally found to violate someone`s personal rights. This is particularly true in human resource issues.

Your in-house standards may be used as evidence for the standard of care under which your department operates. Don`t adopt someone else`s standard, however, unless you intend to follow it. Also, make sure that your members know and follow your standards. There is also a myth that if you call it a guideline instead of a procedure, you can avoid losing a lawsuit. That argument only works if it is a true guideline and firefighters and officers are free to follow or ignore it without penalty. Using terms such as "should" or "may" instead of "shall" and "will" allow greater freedom of action and help to substantiate that a written directive is a guideline instead of a procedure that must be followed to the letter.

DEVELOPING AND IMPLEMENTING SOPs

The development criteria for writing a rule or SOP include the complexity of the task and the department`s experience and training. The frequency of performance of a given task should also be taken into consideration. Many small departments may not achieve the degree of repetition required to assist in committing an operation or method to memory. Finally, the significance of the consequence of an error should always be considered.⁷

Writing SOPs is not as difficult as it seems. A number of tools will be useful in the process--a good copying machine, a telephone, a fax machine, and a computer with a user-friendly word processing program. Use these tools to contact other jurisdictions and to obtain copies of their rules and procedures. Modify them for local use, and fill in the gaps with any procedures that may have been omitted. Remember that your SOP manual should always be a work in progress. As your community changes, new SOPs will become necessary and others will no longer be needed.

Committees are often useful in the development of rules and procedures because the process involves the end-users of the product. A group will typically have more collective knowledge and experience than a single individual, although it is entirely appropriate for an individual to develop the initial draft of a rule or procedure. Committees may also help achieve greater buy-in by the membership for the final document because the committee members may feel a sense of ownership in the process.

The fire chief must convey to committee members his expectations and the parameters under which they will operate for the process to be successful. Otherwise, the committee`s work may be entirely different from the original charge. The chief should also monitor the process to keep the committee on track and to minimize frustration and maintain enthusiasm.

The committee`s makeup is very important to its ultimate success. After all, there is no idea or concept so noble that the appropriate committee cannot kill it. The committee should be representative of the various elements of the department and should be balanced to give everyone in the department representation. There may, of course, be an exception to this recommendation if the item to be considered is of a highly technical nature.

Every department member should be given the opportunity to review the drafts of the proposed rule or procedure prior to adoption. The members` input taps into the collective knowledge and experience of the department and provides an opportunity to evaluate the ideas of others, even if their thoughts prove to be different from those of the committee or individuals guiding the process. Many methods can be used to write rules and SOPs.

The contents of a rules and procedures manual are important. If possible, the manual should be brief and simple. The thicker and more complicated it is, the more likely it will be ignored. Diagrams and illustrations are useful and should be included whenever appropriate. Remember, no matter how well-written a rule or procedure is, it will still be subject to interpretation, sometimes resulting in grievance procedures and necessitating the intervention of civil service boards and arbitrators.

The manual should instruct the user in what to do but not in how to do it unless there is an overriding safety concern or a need for uniformity. For example, there are a number of ways to load a pre-connected line on an apparatus. It is normally desirable, however, that all load their lines in the same manner.

The number of chapters or sections in your manual and the subjects they address will depend on your department`s size, mission, and scope of services. Local or state civil service regulations and bargaining agreements may make some of your manual`s contents more complex or may create the need for additional rules and regulations. In such cases, it may be useful to create multiple volumes--for example, you may want to use separate volumes for the department`s rules and regulations (along with civil service rules and your department`s bargaining agreement) and the SOP manual.

Written EMS protocols are a must, given the litigation risks surrounding the practice of medicine. Emergency medical protocols may be included in your SOP manual or published separately. If your department provides advanced life support services, your operational medical director should promulgate those protocols.

You may write your manual in any of an unlimited number of formats. Choose the one that best fits your department`s needs. Borrowing someone else`s format is okay, provided that it has not been copyrighted. A sample format is presented in Figure 2. The format should at least include a heading with the items in the example. The heading may also include the department`s logo, the names of the individual or group that wrote the standard, and the name of the fire chief.

Rules, general orders, and standard operating procedures should be numbered for easy reference. Various options are available. Some departments use the year and the chronological sequence in which a procedure or order is issued--e.g., SOP 99-001. This works well for numbering general orders and memos. My preference for numbering SOPs is to assign a unique three-digit number to each section or subject area. For example:

100 Rules and Regulations

200 General Administration

300 Hazardous Materials

401 Occupational Safety and Health

500 Maintenance

600 Emergency Operations

700 Emergency Medical Services

800 Communications

900 Fire Prevention

A slight modification of the above system will allow for the promulgation of standards for up to 999 different categories (hopefully, you will never need that many sections). You can then divide each category into subheadings--for example, Section 500, Maintenance, could be divided into the following subcategories:

500 General Maintenance

501 Apparatus and Motor Vehicles

502 Small Tools and Equipment

503 Fire Hose

504 Protective Clothing and Equipment

505 Ground Ladders

506 Generators and Electrical Equipment

507 Buildings and Grounds

Each three-digit subject identifier can be followed by a decimal point and two additional digits--e.g., SOP 502.02 Fire Host Testing--for each procedure. Using this system allows you to assign 100 SOPs to each subheading. This should be more than adequate for even the most complex subjects.

When you begin writing your SOP manual, you may want to alphabetize your subheadings within each category or subject area. As a practical matter, you will soon discover that your original list was not exhaustive, and subsequent procedures will fall into the sequence as they develop. As an organization grows, so will its SOP manual. The early years will be marked by "must-have" standards written in response to a crisis or in anticipation of some pressing need. As organizations mature, their procedures manual may begin to include the subtler "nice-to-have" SOPs that close gaps and tie up loose ends. This is the reason a word processor is such a useful tool: It will allow you to periodically reorganize and renumber your list with relative ease.

SOPs ARE NOT WRITTEN IN STONE

Things change. Therefore, for an SOP manual to remain effective and meaningful, you must revise SOPs to reflect these changes. That is the reason for including an issue date and a revision date in a heading. That is also the reason to keep the manual in a looseleaf binder--it allows you to easily insert the new or revised policies and to discard the out-of-date ones. Although there is no set time increment, I would say that if an SOP has not been revised in the past five years, it is probably no longer being used or has become unnecessary.

If an SOP is no longer necessary, delete it from the manual. Otherwise, the manual may become so thick that it will be cumbersome to use and, therefore, probably ignored. Just as a process was used to develop an SOP, a process should also be used to revise or discard one.

PREEMPTION ISSUES

Your department`s rules and procedures do not supersede those of your municipality or other governing body. They amplify and augment them. It is useful to reference these documents in the applicable department policy or procedure. This will help limit the length of the SOP, since it will be unnecessary to repeat the policies verbatim.

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Figure 2. Sample Format

Name Department

SOP Number

Section or Subject

Issued: Month/Year

Page 1 of N

Revised: Month/Year

TITLE

Scope: This section defines the subject or topic to be addressed by the Standard and identifies the members of the department that are affected by the provisions of the Standard.

Purpose: This section provides the user with the reason for the development and promulgation of the Standard.

General: This section may contain statements of policy if not addressed by a separate heading and may include background information about this topic.

Statement of Policy or the Procedure or Guideline to be Followed: This section identifies the tasks that should be performed, specifies who should perform specific tasks, and lists the order in which the tasks should be performed. More than one section may be necessary to address a complex topic. For example, an SOP on the operation of power saws may address the operating procedure in one section and may require that additional sections be included on fueling procedures, maintenance, and safety precautions.

Responsibility: This section assigns responsibility to specific individuals and groups for complying with the provisions of the Standard and establishes a mechanism for holding members accountable for complying with the Standard.

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Endnotes

1. Schein, E.H. Organizational Culture and Leadership (San Francisco: Jossey-Bass Publishers, 1985).

2. Fayol. H. General and Industrial Management. (Belmont, Calif.: David S. Lake Publishers, 1987).

3. Mehr, R. I. and B.A. Hedges. Risk Management in the Business Enterprise (Homewood, Ill.: Richard D. Irwin. 1963).

4. Brunacini, A.V. Fire Command. (Quincy, Mass.: National Fire Protection Association, 1985).

5. Rukavina, J. "Standards: Can`t live with `em, can`t live without `em," Fire Chief, 42, June 1998, 28-30.

6. Brunacini, A.V., "A Game Plan Reduces Legal Risk," NFPA Journal, 85:30, March/April 1992.

7. Parker, T. J., " A writer`s guide to SOPs," Fire Chief, 39, May 1995, 85-89.

JOHN LEE COOK, JR., a consultant and writer, retired from the fire service after 30 years of service. He had been career chief of Conroe and Denton, Texas, and director of fire and rescue for Loudoun County, Virginia. He has a bachelor`s degree in business administration from Sam Houston State University and a master`s degree in public administration from Southwest Texas State University. He is the author of Standard Operating Procedures and Guidelines (Fire Engineering, 1998).