Risk management
Policies &
Procedures
Clear, written policies and procedures are the foundation of a defensible, well-run midwifery practice.
They help ensure consistency, reduce misunderstandings, support team communication, and demonstrate to regulators and insurers that your practice is intentional and organized.
This page will guide you through how to develop (or revise) your policies and procedures, and will include downloadable templates and examples specific to licensed midwifery and birth center practice in Washington State.
What’s the Difference Between a Policy and a Procedure?
Key differences:
- Policy = What your practice does and why
- Procedure = How your practice carries it out
Example:
Policy: All clients will receive informed consent prior to performing vaginal exams.
Procedure: The midwife will explain the purpose and nature of the exam using plain language, obtain verbal consent, and document the discussion and consent in the chart.
Why They Matter for Risk Management
Well-written policies and procedures can:
- Prevent inconsistent or unsafe practices
- Clarify roles and expectations in group practices
- Demonstrate compliance with Washington State regulations
- Strengthen your legal defense if care is ever questioned
Required Policies and Procedures in Washington State
Licensed midwives and childbirth centers in Washington are required by state law to develop and maintain specific written policies and procedures. These ensure compliance with RCW and WAC regulations and help safeguard quality of care for clients and their newborns. There are additional policies & procedures that are a good idea for all practices to have. Below is a summary of the core policies and procedures required by law, as well as others that are recommended by the JUA.
For Licensed Midwives
As required by RCW 18.50 and WAC 246-834
Must have these policies and procedures:
- Written Plan for Consultation, Transfer, and Transport (RCW 18.50.108)
- Legend Drugs & Devices (WAC 246-834-250)
Good idea to have these policies and procedures:
- Continuing Education Tracking (WAC 246-834-355)
- Participation in a Quality Improvement Program (WAC 246-834-360)
- Data Collection and Submission (WAC 246-834-370)
- Reporting of Adverse Health Events (WAC 246-329-045, RCW 70.56)
- Eligibility for Home Birth
- Home Birth Site Requirements
- Laboratory Testing Offered/Not Offered
- Normal Prenatal Care
- Normal Intrapartum Care
- Normal Postpartum Care
- Normal Newborn Care
- Mechanism for Client Feedback
- Storage, Maintenance and Periodic Inspection of Supplies/Equipment
- Storage & Disposal of Sharps
- Storage & Disposal of Placenta
- 24-Hour Coverage of Practice
- Complaint Process/Conflict Resolution
- Termination of Client/Provider Relationship
- Midwife’s Right to Decline Client
- Roles of Staff/Birth Assistants/Students in Client Care
- Retention of Medical Records
- Storage and Security of Medical Records
- Latex Allergies
For Licensed Birth Centers
As required by RCW 18.46 and WAC 246-329
Must have these policies and procedures:
- Care of Clients Within or On the Birth Center Premises (WAC 246-329-030)
- Requirements for Clinical Staff Membership (WAC 246-329-030)
- Delineation of Clinical Privileges (WAC 246-329-030)
- Organization of Clinical Staff (WAC 246-329-030)
- Admission to the Birth Center (WAC 246-329-085)
- Discharge from the Birth Center (WAC 246-329-085)
- Non-Discrimination in Employment (WAC 246-329-110) – for birth centers employing 8+ people
- Staff Roles and Credentialing Agreements (WAC 246-329-110)
- Verification of Clinical Staff Credentials, Skills, Training (WAC 246-329-110)
- Orientation of Staff to Policies and Procedures (WAC 246-329-110)
- CPR and NRP Training Required (WAC 246-329-110)
- Infection Control Practices for Clinical Staff (WAC 246-329-110), including TB screening and Hep B vaccination
- Performance Evaluations of Birth Center Personnel (WAC 246-329-110)
- Criminal Background Inquiries and Disclosure Statements for Birth Center Personnel (WAC 246-329-110)
- Maintenance of Personnel Files (WAC 246-329-110)
- Definition of Low-Risk Client (WAC 246-329-120)
- Ineligibility for Birth Center Services (WAC 246-329-120)
- Identification and Transfer of Ineligible Clients (WAC 246-329-120) – must include antepartum, intrapartum and immediate postpartum
- Consultation, Referral, Transfer, and Transport from Birth Center (WAC 246-329-120)
- Transfer and Discharge of Neonates (WAC 246-329-120)
- Medications & Testing for HIV+ Clients (WAC 246-329-120) if applicable
- Rapid HIV Testing for Clients with Unknown HIV Status on Admission to the Birth Center (WAC 246-329-120)
- Fetal Heart Rate Monitoring During Labor (WAC 246-329-120)
- Provision of MMR Vaccine for Nonimmune Postpartum Clients (WAC 246-329-120)
- Provision of RhIG for Rh-Negative Postpartum Clients (WAC 246-329-120)
- 24-Hour Availability of Transport from Birth Center (WAC 246-329-120)
- Informed Consent for Birth Center Services (WAC 246-329-120)
- Assurance of Required Intrapartum and Postpartum/Newborn Care (WAC 246-329-120)
- Provision of Medications, Legend Drugs and Devices (WAC 246-329-120, WAC 246-329-130)
- Infection Control for Housekeeping (WAC 246-329-120)
- Communicable Disease Reporting (WAC 246-329-120)
- Addressing Communication Needs of Clients (WAC 246-329-120)
- Abuse/Neglect Reporting (WAC 246-329-120)
- Emergency Care of Client (WAC 246-329-120)
- Death of a Client (WAC 246-329-120)
- Service Delivery During Disasters (WAC 246-329-120)
- Waived Laboratory Tests (WAC 246-329-120, WAC 246-338)
- Client Records Management & Confidentiality (WAC 246-329-140)
- Required Elements of Client Record (WAC 246-329-140)
- Client Records from Contracted/Privileged Midwives (WAC 246-329-140)
- Retention and Storage of Client Records (WAC 246-329-140), including upon cessation of operation of the birth center
- Orders for Drug Administration in Birth Center (WAC 246-329-150)
- Drugs & Devices Used in Birth Center (WAC 246-329-150)
- Drug Storage, Access & Compliance (WAC 246-329-150)
- Food Storage and/or Preparation (WAC 246-329-160)
- Emergency Preparedness & Fire Protection (WAC 246-329-170)
Good idea to have these policies and procedures:
- Reporting of Adverse Health Events (WAC 246-329-045, RCW 70.56)
- Quality Improvement (WAC 246-329-180)
- Complaint Process/Conflict Resolution
How to Develop or Revise a Policy/Procedure
1
Identify the issue. Focus on topics that impact client safety, documentation, or regulatory compliance.
2
Check for relevant laws or standards. Review WA Dept of Health licensing rules, MAWS or WARM standards.
3
Draft the policy and its associated procedure. You can put them both on the same page. Keep language clear and specific to your practice. Include what, who, when, and how.
- DO keep it simple; too many details can come back to bite you. Describe what you will do every time in a general way that allows for flexibility and clinical judgment.
- DON’T include information that may soon become outdated (e.g., use positions, not people’s names)
4
Review and revise. Share with your team, backup midwives, or a JUA risk consultant for feedback.
5
Document and train. Store policies in a shared location. Make sure everyone on your team knows what’s expected.
Templates and Examples
The sample documents, templates, and guidance provided by the Washington JUA are intended for informational and educational purposes only. They do not constitute legal advice, clinical directives, or regulatory requirements. Each midwifery practice is responsible for reviewing and adapting these materials in accordance with current Washington State laws, professional standards, and the specific needs of their practice. The Washington JUA assumes no responsibility for how these resources are used or interpreted.
Templates
Examples
– Policy & Procedure: Charting and Clinical Documentation (pdf)
– Policy & Procedure: Informed Consent (pdf)
Frequently Asked Questions
Do I need written policies if I’m a solo midwife?
Yes. Written policies show that you practice with intention, and they help clarify your process for clients, students, and regulators.
Can I adapt a birth center’s policies for my home birth practice?
You can use them for inspiration, but policies should reflect your actual practice and settings. You don’t want to be held to a policy you don’t follow.
How often should I review and update my policies and procedures?
At minimum, you should review all policies annually and document the review date. Policies should also be updated any time there is a change in Washington State regulations, your clinical practices, team structure, or lessons learned from an incident or near miss. Keeping policies current shows regulators and insurers that your practice is proactive and safety-focused.
Should I include references to state laws or clinical guidelines in my policies?
Yes – referencing relevant WACs, RCWs, or evidence-based guidelines can strengthen your policies and show that they’re grounded in current standards. Just make sure any citations are accurate and that your procedures actually align with what you reference.
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