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Version: 1.0.0
Last Updated: 2026-01-28
Module: GR (Governance & Risk)
Status: Active
Purpose: This guide helps compliance officers and administrators create, manage, and monitor procedures.
Overview
The Procedures Management module enables compliance officers to create visual step-by-step procedures, link them to policies, track executions, and use AI to generate procedure drafts.
Admin Responsibilities
| Responsibility | Description |
|---|
| Create Procedures | Build visual workflows with step-by-step instructions |
| Manage Lifecycle | Move procedures through draft → review → approved |
| Link to Policies | Connect procedures to implementing policies |
| Monitor Compliance | Track procedure execution across the organization |
| Use AI Generation | Generate procedure drafts from policy content |
Prerequisites
Required Permissions
Administrators need these permissions:
| Permission | Purpose |
|---|
gr.procedures.admin | Full administrative access to procedures |
gr.procedures.create | Create new procedures |
gr.procedures.edit | Edit existing procedures |
gr.procedures.approve | Change procedure status |
gr.settings.manage | Configure module settings |
Creating Procedures
Quick Create
- Navigate to GR → Procedures
- Click Add Procedure
- Fill in required fields:
- Title: Clear, descriptive name (e.g., “SOP-001: Medication Administration”)
- Category: Clinical, Operational, Safety, HR, Financial, IT, Emergency, Other
- Description: Brief overview of procedure purpose
- Click Save to create a draft
Using AI Generation
Generate procedure drafts from existing policies:
- Navigate to GR → Procedures → New
- Click Generate with AI button
- Select an approved policy from the dropdown
- (Optional) Add additional context for the AI
- Click Generate Procedure
- Review the generated steps and confidence score
- Click Apply to Procedure to populate the editor
- Edit and refine as needed
Note: AI generation is only available when AI features are enabled for your organization.
Visual Workflow Editor
Canvas Overview
The procedure editor uses a visual canvas where you can:
- Add different step types
- Position steps by dragging
- Connect steps with edges
- Configure step properties
Adding Steps
- Open procedure in edit mode
- Click step type button in the toolbar:
- Action: Standard task
- Decision: Branch point
- Verify: Sign-off step
- Reference: Link to document
- System: Automated action
- New step appears on canvas
- Drag to position
Configuring Steps
Click on any step to open the properties panel:
| Property | Description |
|---|
| Title | Clear, concise step name |
| Instructions | Detailed step-by-step instructions |
| Responsible Role | Who performs this step (e.g., “Nurse”, “Manager”) |
| Duration | Estimated time in minutes |
| Requires Signature | Enable for verification steps |
| Verification Criteria | What must be verified (for verification steps) |
| Decision Options | Branch labels (for decision steps) |
Connecting Steps
- Hover over a step’s bottom handle (output)
- Drag to another step’s top handle (input)
- Edge connects the steps
- Label edges as needed (especially for decisions)
Decision Branches
For decision steps:
- Add the decision step to the canvas
- Configure decision options (e.g., “Yes”, “No”, “Escalate”)
- Each option creates a separate output handle
- Connect each handle to the appropriate next step
- Label each edge with the decision option
Procedure Lifecycle
Status Workflow
| Status | Description | Who Can View |
|---|
| Draft | Being created/edited | Compliance officers only |
| Review | Under review before approval | Compliance officers only |
| Approved | Active procedure | All staff |
| Deprecated | Being phased out | All staff (with warning) |
| Archived | Historical record | Compliance officers only |
Approving Procedures
Before approving:
- Review all steps and connections
- Verify linked policy (if applicable)
- Check that all steps have clear instructions
- Ensure responsible roles are assigned
To approve:
- Open the procedure
- Click Change Status button
- Select Approved
- Set effective date
- Procedure becomes visible to staff
Creating New Versions
When updating an approved procedure:
- Open the approved procedure
- Click Create Version
- Enter a change summary
- Version snapshot is created (immutable)
- Continue editing the current version
- Re-approve when changes are complete
Linking to Policies
Why Link Procedures to Policies?
- Demonstrates policy implementation
- Enables compliance traceability
- Required for accreditation audits
- Shows staff “the why” behind procedures
Creating Links
- Open procedure in edit mode
- Find “Implements Policy” dropdown
- Select the policy this procedure implements
- Link is created automatically
- Appears on both procedure and policy detail pages
Link Types
| Type | Description |
|---|
| Implements | Procedure implements the policy requirements |
| References | Procedure references but doesn’t fully implement |
| Related | Procedure is related to the policy |
Monitoring Executions
Execution Dashboard
View all procedure executions:
- Navigate to GR → Procedures
- Open any procedure
- Click the Executions tab
Execution status breakdown:
| Status | Description |
|---|
| In Progress | Currently being executed |
| Completed | Successfully finished |
| Abandoned | Started but not completed |
Compliance Reporting
Use execution data for:
- Track which procedures are being followed
- Identify procedures with low execution rates
- Audit execution records for accreditation
- Verify staff compliance with SOPs
Execution Details
View execution details to see:
- Who executed the procedure
- When each step was completed
- Notes added during execution
- Decisions made at branch points
- Electronic signatures captured
Module Settings
Available Settings
Navigate to GR → Settings → Procedures:
| Setting | Default | Description |
|---|
procedure_number_prefix | ”SOP” | Prefix for auto-numbering |
procedure_review_reminder_days | 30 | Days before review due |
procedure_auto_save_interval_seconds | 30 | Auto-save frequency in editor |
require_policy_link | false | Require procedures to link to policies |
Configuring Settings
- Navigate to GR → Settings
- Open “Procedures” tab
- Modify settings as needed
- Click Save
AI Generation Best Practices
Getting Good Results
- Select clear policies: Policies with detailed requirements generate better procedures
- Add context: Describe specific roles, environment, or constraints
- Review confidence score: Higher scores indicate better AI understanding
- Edit generated content: Always review and refine AI output
What AI Generates
- Procedure title and description
- Ordered steps with appropriate types
- Responsible role suggestions
- Time estimates
- Verification points
- Decision branches
What to Review
- Verify step order makes sense
- Check role assignments are correct
- Ensure decision options are complete
- Add organization-specific details
- Remove any generic placeholder content
Troubleshooting
Common Issues
Issue: Staff Can’t See Procedure
Symptoms: Staff report procedure not visible
Cause: Procedure may be in draft/review status
Resolution:
- Check procedure status
- If draft/review, approve the procedure
- Set effective date if needed
Issue: AI Generation Not Working
Symptoms: Generate with AI button missing or failing
Cause: AI features not enabled for organization
Resolution:
- Verify AI compliance features enabled in GR settings
- Check LOVABLE_API_KEY secret is configured
- Contact administrator if still not working
Issue: Execution Not Recording
Symptoms: Steps complete but execution not saved
Cause: Permission or connectivity issue
Resolution:
- Check user has
gr.procedures.execute permission
- Verify network connectivity
- Refresh page and try again
Escalation Path
If issues can’t be resolved:
- Check system logs for errors
- Review recent changes to procedures
- Contact technical support with:
- Error messages
- Steps to reproduce
- User and organization details
Best Practices
Creating Effective Procedures
- ✅ Keep step instructions clear and actionable
- ✅ Use active voice (“Review the form” not “The form should be reviewed”)
- ✅ Assign specific roles, not generic “staff”
- ✅ Include time estimates for each step
- ✅ Add verification steps after critical actions
Managing Procedures
- ✅ Review procedures quarterly for accuracy
- ✅ Update when policies change
- ✅ Archive rather than delete outdated procedures
- ✅ Use version history to track changes
Monitoring Compliance
- ✅ Check execution rates regularly
- ✅ Follow up on abandoned executions
- ✅ Use execution data in audits
- ✅ Identify training needs from execution patterns
Data Management
Version History
All procedure versions are stored:
- Version snapshots are immutable
- Change summaries document updates
- Previous versions available for audit
Data Retention
| Data Type | Retention Period | Notes |
|---|
| Active procedures | Indefinite | Until archived |
| Archived procedures | 7 years | Per compliance requirements |
| Execution records | 7 years | Per audit requirements |
| Version history | Indefinite | For traceability |
- User Guide:
docs/gr/procedure-user-guide.md - For staff members
- Policy Admin Guide:
docs/gr/policy-admin-guide.md - Managing linked policies
- AI Compliance Guide:
docs/gr/ai-compliance-admin-guide.md - AI features
- Module Overview:
docs/gr/index.md - GR module documentation
Last Updated: 2026-01-28
Technical Support: Contact your system administrator