Let’s face it—policies matter.
We all need—especially in hospitals—a good way to track our policies back to compliance standards and enforce them through various procedures
The problem we’ve seen is that hospitals are often managing these policies and procedures in Word documents, Sharepoint files, or even in Excel spreadsheets, making the task of enforcing compliance—ensuring that procedures and policies match up with changes in compliance—a real heck of a task.
How are policies and procedures getting misplaced, outdated, unseen, or even lost?
Typically compliance experts have found root causes behind hospitals with poor, outdated, or ineffective policies and procedures stem from a few behavioral or tool-related gaps within their organizations.
Below are the top 4:
Policies and procedures managed in documents or file shares—we see this one all the time, even among some very organized compliance or security officers. What results from simply having P and P stored in Word Docs or Sharepoint, for example, are haphazard files that over time either become outdated, misplaced, or even lost.
Reactive and inefficient policy programs—when auditing policies and procedures, often compliance experts find a lack of coordinated policy updating and staff training around policy and procedural changes. When policy changes are reactive and aren’t fully implemented throughout associated procedures (because each procedure is not matched up to an associated policy), compliance becomes very reactive and quite messy.
Standards change—one of the biggest headaches we’ve seen among people that deal with policies and procedures is being able to easily make changes as the standard documents (what the policies are based on) change.
Rogue and out of date policies—in many cases, published policies are not reviewed and maintained on a regular basis. In fact, most hospitals have policies that might not have been reviewed for years, leaving uncertainty as to whether standard requirements have changed. In addition, if your organization is maintaining documents in Word files, policies may have been written or published that never were fully implemented.
Bottom line: policies and procedures are hard to manage. There are so many of them to keep track of, too many that are changing and many that fall of the radar. Your hospital needs a better solution.
The Inevitable Failure of Policy Management
Hospitals often lack a coordinated strategy for policy development, maintenance, communication of policies and training around those policies. Generally, the ad hoc approach to policy and procedure management exposes your hospital’s liabilities.
Liabilities are intensified by the fact that compliance programs affect nearly every person involved in supporting your hospital, including internal employees as well as third party contractors.
To defend your hospital against any lawsuits, you must be able to show a detailed history of what your policies were when, how they were communicated to your team, an audit of who read them, who was trained on them, who attested to them, and what exceptions were granted. If you lack any of this—or even lack historical documentation of what your Policies and Procedures were prior to any changes, your organization might be held responsible for an action that may or may not have occurred to expected practices at that time.
With today’s complex operations within hospitals and greater state and federal regulatory compliance environments, a well-defined policy and procedure management program is critical to keeping your hospital safe from false lawsuits and claims.
The take home: haphazard documentation around policy and procedures is all too common within hospitals.
A solution?
A policy and procedure management system that can record historical changes to your documents, match standards to policies and policies to procedures, and make sure that everyone has read and affirmed your policies in order to keep your hospital legally above board.
While most solutions—even the expensive ones—do not deliver what they promise (what’s outlined in the solution).
Healthcurity’s Policy and Procedure portal DOES do all of the things mentioned. It’s developed with hospital compliance officers and administrators in mind (actually with a lot of their feedback) AND it is completely included in our managed solutions. Interested in learning more about the Healthcurity P and P? Ask us about our webinar series directly on how to better manage your Policies and Procedures.
