Policy management is the process of creating, communicating, and maintaining policies and procedures within an organization. An effective policy management system can mitigate risk in two ways. First, it makes policies more quickly accessible to direct care staff, guiding care and safety decisions. Second, it can protect an organization from litigation by staying up to date on accreditation standards and creating an audit trail in the case of legal action. Because the process of managing policies can be expensive and time consuming, hospital boards should make the implementation of an efficient policy management system a priority. A comprehensive and well-managed set of policies can support GRC activities by communicating boundaries and expectations, establishing a culture of compliance within the organization, protecting the organization from litigation, and helping achieve the organization’s objectives.
Policy management can be described in the following four step cycle:
1. Creation: When a need is identified within an organization, a policy is written and goes through an approval process.
2. Communication: After creation and approval, a policy is communicated to staff. This includes publication of the policy, training, and attestation.
3. Management: Throughout the life of the policy, it is consistently enforced and exceptions are managed when applicable.
4. Maintenance: Policies are reviewed regularly, updated, and archived when necessary (Open Compliance & Ethics Group, 2012).
Effective policy management can significantly mitigate risk in a health care organization. When policies that guide patient care and employee safety are easily accessible, they will be consulted more frequently, ensuring that employees are following proper procedures. Thus, risky situations for staff members and patients are avoided.
In addition to avoiding safety risks, an effective policy management system can protect an organization from litigation. Regulatory agencies require health care facilities to have a comprehensive, well-managed, and fully adhered to set of policies. An effective policy management system can do this, in addition to showing audit trails and a history of interactions with certain policies in the case of legal action (Kontaxis & Hines).
Policy management should be a priority for hospital boards. Inefficient management of policies is time consuming and expensive. One study showed that large short term acute care facilities with 1,000+ beds had an average of 5,198 active policies that had to go through annual approvals. Each policy went through an average of 2.08 approval steps, meaning that large hospitals went through about 10,812 approval steps per year, with each step lasting an average of 4.38 days. Furthermore, responsibility for managing policies and procedures was distributed among several entities (Shah, 2011). With this information, hospital boards can begin the process of developing a more efficient system to manage policies. Hospital boards should understand that an efficient approach to policy management is simple and accountable, has designated leaders, takes advantage of new technology, and allows governance, risk, and compliance specialists to better target resources.
Governance, risk, and compliance refers to an organization’s capability to reliably achieve objectives while addressing uncertainty and acting with integrity. A well-managed and maintained policy system directly supports this. It helps define, articulate, and communicate boundaries and expectations, while guiding desired conduct and establishing a culture of compliance within the organization. Additionally, the system can communicate risk limits and protect the organization from litigation. Finally, it helps achieve the organization’s objectives and explains governance and accountability structures (Open Compliance & Ethics Group, 2012).
A comprehensive policy management system should be the foundation of a facility’s governance, risk, and compliance program in order to mitigate risks and avoid litigation. Simply having a set of policies is not enough to protect your patients, your employees, and your facility. In today’s ever-changing regulatory environment, it is critical to have a policy management system that can adjust and adapt to the needs of your organization.
Kontaxis, J., & Hines, E. (n.d.). Best Practices for Managing Policies and Procedures in Healthcare.
Retrieved April 26, 2013, from Benchmark Technologies International Inc.:
Open Compliance & Ethics Group. (2012). Policy Management: Visualizing an Effective Capability.
Retrieved May 1, 2013, from Governance, Risk Management and Compliance Research 20/20:
Shah, S. N. (2011, October 30). Guest Article: Policy management software for hospitals and clinics helps with
change management. Retrieved April 26, 2013, from The Healthcare IT Guy: