Guide to healthcare policy and procedure management

Effectively managing policies and procedures in healthcare have a far-reaching positive effect.

July 12, 2021

Article highlights

Healthcare systems are alike in many different ways. They're concerned with patient care. They want to save and improve as many lives as they can. They're concerned about risks to their patients, their staff, and their resources.

But there are many different kinds of healthcare organizations, each providing a different type of care to a different patient population. Some healthcare organizations may only serve elderly patients, others may only treat children with terminal diseases. Some treat patients at home, while others have patients who stay in the facility for months and years. Some focus strictly on the mind and a person's behavior, while others are dedicated to a patient's inner workings via surgery.

The one thing all of these healthcare organizations have in common is the need for a strong policy and procedure management solution. It helps them set standards and best practices, create rules that staff members are expected to follow, and mitigate risk and reduce liability against lawsuits and regulatory problems.

Different types of healthcare organizations

Though needs can vary between organizations, effective healthcare policy and procedure management is important across the board. Typically, the types of healthcare organizations that are most concerned with accreditation and effective policies and procedures are:

  • Hospitals
  • Health systems
  • Behavioral health centers
  • Health plans
  • Long-term care centers
  • Skilled nursing facilities
  • Home health
  • Ambulatory surgery centers
  • Student health centers
  • Labs and Pharmacies

They need the most current content in order to achieve everyday readiness, provide top patient care, and help meet accreditation requirements.

Even though there are different types of healthcare organizations, healthcare policy and procedure management is still one of the most important issues they face. Without effective policy management, they face a slew of problems and difficulties.

PowerDMS has worked with a number of different healthcare organizations. Learn more about the types of healthcare facilities we help.

Importance of policies and procedures in healthcare

It may not sound like it at first, but healthcare policy and procedure management could mean the difference between life and death for patients. Staff members working from contradictory procedures or making decisions based on out-of-date policies can lead to errors, incomplete information, or incorrect decisions. When that happens, a patient's safety – or even the staff's – can be compromised.

Importance of policies and procedures for hospitals

Hospitals not only need up-to-date policies and procedures for accreditation purposes, everyone on the staff needs to be able to access their policy manual and all the information that applies to them. A policy management software solution can provide this kind of centralized, "single source of truth" access. 

Since many hospital staff members don't have their own offices or their desks, they've got nowhere to store a hard-copy binder. In some cases, many of them don't have continual access to a computer where they can access their policy manual when they have a chance to sit down.

It's important that staffers be able to access their policies and procedures manual via a mobile phone or tablet. If staff members have a question, they can search it out on their mobile device immediately, rather than waiting for time to find a computer and look it up.

Having centralized policies and procedures can also speed up the accreditation process by several months. Not only can compliance administrators push out new policies to staff, but it's also possible to monitor whether staff has read the policies, and even track the signatures of those who have read the updates. Then it's just a question of sharing that information with the accreditation agencies, and it can shave months off the time.

With the right software, compliance administrators can push out new policies to staff, monitor read-receipts, and track signatures. But the real time-saver is being able to crosswalk policies and proofs of compliance to accreditation standards. Not only that, all your work can be carried over from one accreditation cycle to the next.

Learn more about policy and procedure management for hospitals.

Importance of policies and procedures for student health services

Just like many hospitals, student health services are accredited by the Accreditation Association for Ambulatory Health Care (AAAHC), the Joint Commission, and the National Committee for Quality Assurance (NCQA) to name a few. They set the standards for most healthcare centers, including student health centers.

In fact, the AAAHC holds ambulatory health clinics to a higher standard, which means they're measured on things like research, patient care, and even things like IT policies for storing patient records.

In addition to the reasons we discussed for hospitals, student health services are also able to operate more efficiently. Student health services administrators often say management issues are the biggest challenges they face, and that can include poor patient outcomes, governmental mandates, and ethical issues.

Finally, a healthcare policy and procedure management solution can help with your accreditation efforts, often shaving months of time off the entire review process.

Learn more about policy and procedure management for student health services.

Importance of policies and procedures for long-term care center and skilled nursing facilities

Long-term care centers and nursing facilities have many of their own challenges. While hospitals are generally short-term care centers, the long-term centers and nursing facilities plan on having their patients for months and years. Needless to say, they have their own healthcare policy and procedure management issues. 

  • Patient care policies are the most comprehensive policies in a manual because they specify how staff should provide care for patients. Some of the policies are more administrative, but others deal with patient safety.
  • Medicine policies cover how medications, prescriptions, and dosages are tracked and inventoried. They prevent deadly and dangerous errors, which make them some of the most important policies and procedures in healthcare.
  • Administrative policies cover day-to-day business management of the long-term care centers and nursing facilities., including vendor requirements, credentials, equipment management, purchasing, and record keeping.
  • HR policies cover personnel issues for all of your organization's staffers. They can cover vacation and sick days, shift policies, sexual harassment, and bullying.
  • IT policies are dictated by HIPAA and HITECH governmental regulations. They should create safeguards for all IT systems to protect patient and personnel information.

To be clear, every healthcare operation has these policies in their healthcare policy and procedure management solution. But each type of operation will have different policies that affect their different populations.

Even so, a lot of content used in these policy manuals comes from accreditation groups like AAAHC and NCQA, which set standards for all kinds of healthcare organizations. They even cover HR and IT policies for those groups.

Learn more about the importance of policies and procedures for student health services.

Best practices for risk mitigation in healthcare

You can't completely eliminate risk in any healthcare organization (or any organization, really). But having an extensive policy and procedure manual can go a long way to mitigating that risk.

As we've discussed, effective policy management sets standards for care, operations management, IT management, and even personnel issues. Spelling out your policies and procedures, and making them accessible to staff can go a long way to protect your patients, staff, and your entire healthcare organization. Here's how.

Incorporate changing industry standards

As the technology and science around healthcare change, so do the industry standards. This means you need to keep up with changes to policies, best practices, and even the standards set forth by accreditation agencies. Not only can older practices and policies be dangerous, but these new practices can save even more people and help reduce their pain.

According to the American Society for Healthcare Risk Management, "healthcare risk managers must adapt and be proactive in developing and implementing initiatives that enhance organizational performance and productivity while improving patient outcomes."

The University of Scranton recommends incorporating standards from organizations like the Department of Health and Human Services, Food and Drug Administration (FDA), and the American Society for Healthcare Risk Management (ASHRM).

Regularly update policies to meet new industry standards

The best way to ensure your policies remain updated is to actually schedule regular updates. Make time on your calendar to review all policies to make sure they meet accreditation and industry standards.

Your organization should encourage communication among staff to identify problem areas and ensure proper accountability measures are in place. And when updating policies, be sure to ask the people who actually work in these areas for ideas and suggestions on how to improve. They are the best sources for that kind of information.

Get best practices on writing policies and procedures in healthcare.

Put your policies in the cloud

Moving to a cloud-based policy management solution is critical to healthcare policy and procedure management. It makes the content accessible to any staff member from anywhere. Rather than printing out thousands of policies and putting them in hundreds of binders, you can share your manual updates electronically, track the readership of the policies, and even check signature verification.

Your staff members only need a mobile phone or tablet, although they can access everything via a laptop if they choose. This is especially important for health systems with multiple campuses and remote employees.

Train and test your employees on their understanding of policies

Part of your accreditation and risk mitigation efforts means showing that you have taken the steps to inform and train all employees about new and existing policies. With training management software like PowerDMS, you can train and educate employees about policies anytime, anywhere.

You can also test their knowledge with customizable testing to ensure they all know and understand these policies, especially those related to new standards. This ensures you have records of the tests, which can be helpful during accreditation or litigation.

Keep detailed records of policy distribution and sign-offs

Showing an audit trail can shield your organization from accusations of negligence: After all, having great policies won't do much good if you can't show that they've been read, understood, signed, and tested on. 

Documenting when employees have read new or revised policies can help protect against negligence claims and assists with your accreditation. Cloud-based policy manuals allow you to pull these archived records if needed. A full version history of who signed, edited, and approved a policy could provide crucial evidence in litigation situations.

Want to learn more about risk mitigation in healthcare? Read our article on that subject now.

Healthcare policy and procedure management made simple

The right software simplifies healthcare policy and procedure management, saving you time, money, and stress. Learn more about healthcare policy management software here.

PowerDMS is specialized for healthcare organizations. So if you’re looking to simplify your day-to-day operations, streamline the accreditation process, improve patient care, and save your policy admins or accreditation managers time, look no further..

We offer a healthcare policy management solution that provides access to standards from accrediting agencies like AAAHC, CIHQ, DNV, NCCHC, and TJC.. It also lets you notify staff about new updates, train them on those updates, track their test scores and attestation, and in general, improve the overall function of your healthcare organization.

Discover how PowerDMS is specialized for the needs and challenges of organizations like yours.

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