As we continue to make our way through the healthcare industry, we have noticed various trends that have occurred in the past decade. One such trend, complying to rules and regulations, has become permanent as more and more healthcare facilities are required to keep up with compliance by the governing boards. Healthcare facilities create and maintain thousands of policy and procedure manuals. Having an effective policy management system can help support a hospital board’s risk and compliance oversight responsibilities. In general, hospital policies include daily operation guides that range from administration and human resources, to direct care and use of medication. Due to the rigid rules and expectations from the regulatory boards, it is imperative that healthcare organizations organize and maintain a sound policy management system. To that end, employing a powerful, yet simple, policy management software, such as PolicyManager, may make a great difference in ensuring the healthcare organization is on par with its requirements. However, it should be noted that each organization has its own unique needs, and that not all policy management software would be able to cater them all. Regardless of which software you may employ, this article generally outlines the nature of compliance and why it is important.
An effective organization and development of a policy management system, can help establish a culture of compliance, which then leads the organization to achieve its objectives by mitigating risks. The notable importance of sound policy management system is suggested to be a part of effective compliance program. However, hospitals must ensure that the policies and procedure manuals are written clearly, readable, readily available, regularly updated, and are relevant to the daily responsibilities. The Office of Inspector General strongly advises that hospitals should conduct regular checks to ensure its staff members read and understand internal policies and procedures, and encourages the governing board to be involved in compliance program development and oversight.
Alarmingly, some hospitals have reported that they are still under the manual system of creating and storing physical copies of policies and procedure manuals in binders, housing them in multiple locations. This places the organizations at risk of non-compliance. For instance, one such hospital was asked to locate specific policies during a 2012 accreditation survey, during which they were unable to do so, and as a result the survey was adversely affected. Governing boards play a critical role in ensuring that their organization is actively engaging in development and management of an effective policy management system, as part of risk management and compliance efforts. One way for the board to oversee such activities is by conducting regular reviews of the hospital’s internal control systems. As part of such a review, boards should ensure that policies are managed in ways that:
- Are simple and accountable,
- Have designated internal leaders responsible for oversight,
- Ensure quick and ready access to policies,
- Allow easy creation and regular review,
- Link to related standards and regulations,
- Take advantage of new technology that can reduce the time and expense of using manual, paper-based systems,
- Allow governance, risk, and compliance activities to identify areas for improvement and target resources to address them.
It is imperative for the board to be provided with data and performance benchmarks relevant to effective policy management. In the OIG report, “Driving for Quality in Acute Cancer: A Board of Directors Dashboard,” it is suggested that a performance dashboard could include such metrics as, numbers of new and updated policies and the amount of time spent accessing key policies, along with benchmark data for comparison. This will help the boards of the respective facilities to recognize areas of improvement by comparing their facilities’ performance against industry standards.
A healthcare organization can effectively achieve its governance, risk, and compliance objectives through the support of a sound policy management system. Thereby, it helps define the culture of compliance amongst staff members of a healthcare facility, while also articulate and communicate boundaries and expectations, guide desired conduct, and reduce the risks of fines and litigation that may arise from failure of complying with regulatory requirements.
At PolicyMedical, we work long and hard to ensure our PolicyManager helps healthcare facilities manage their policy management system as painlessly as possible. Our solutions are designed to be powerful, yet simple, so you and your facility members can reap as many benefits as possible. With that said, we recognize that we may not be able to cater every organization’s needs and that other vendors may have offerings that may be a better match. Regardless, we are more than happy to help you come to the right conclusion, even if it means another vendor is the right option. Please, contact us if you need any assistance. Alternatively, you may book a demo to witness our solutions in live action.