Ultimate Guide to Healthcare Policy and Procedure Management

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

March 1, 2022

Article Highlights:

Regardless of size, focus, or location, healthcare systems all have a common purpose: they're focused on patient care. They want to save and improve as many lives as possible and 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 medical treatment 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.

One thing all 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

Although 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 on their plate. Without effective policy management, they face a slew of problems and difficulties.

Importance of policies and procedures in healthcare

It may sound dramatic, 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 Staff members working from contradictory procedures or making decisions based on out-of-date policies can lead to errors, incomplete information, or incorrect decisions.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.

For example, if a staff member isn't aware of a new medicine policy, he or she may administer the wrong amount of a drug or distribute the wrong type of drug to a patient. This is why a healthcare system needs policies and procedures in the first place: to make sure everyone is "singing from the same songbook" when it comes to the standard of care the hospital or healthcare system provides.

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 employees don't have their own offices or desks, they have 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.

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, standard of care, and even IT policies for storing patients' medical 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 reducing the time of the entire review process by months.

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

For long-term care centers 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 housing 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 and clinical 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, unlike administrative 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/federal 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 has different policies that affect their varying 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.

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 in 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 are a few best practices for mitigating risk.

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.

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.

Create a quality manual or quality management plan

A quality manual details a hospital's quality management system in clear and simple language. It provides the framework of the quality system requirements. A hospital quality manual is the how-to document that spells out the hospital's operational processes and what steps they will take to provide their standard of care. It can serve as a hospital policy and procedures manual, especially if the hospital is trying to meet DNV NIAHO or other accreditation standards.

The quality manual has to be reviewed and approved on an annual basis. For larger hospitals, this is usually done by an interdisciplinary team consisting of a combination of senior leadership, medical staff, nursing, quality/risk management, safety, pharmacy services, and ancillary services.

Your quality manual should include risk-based thinking, documented surveys, internal surveys and audits, corrective actions to take following nonconformity, measurable quality objectives, and how you'll determine your effectiveness.

You can learn more about creating an effective quality manual on our website.

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 check their knowledge with customizable testing to ensure they all know and understand your policies, especially those related to new standards. This also provides you with 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 healthcare employees have read new or revised policies can help protect against negligence claims and assist 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

At their basic level, policies create a set of rules and procedures for your staff to follow when providing patient care, distributing medicine and supplies, or responding to an emergency.

Having healthcare policies and procedures in place can also protect your organization from litigation. If nothing else, they provide evidence that you already had safety parameters in place. And when you can demonstrate that your employees have reviewed those policies, been trained on them, and have been tested on them, a plaintiff's lawyer can't claim that your organization doesn't have the appropriate training. This also protects your employees and their patients on a daily basis.

In large part, this is why healthcare policy management is so important. The right healthcare policy management software simplifies healthcare policy and procedure management, saving you time, money, and stress. 

Learn more about different types of policy management software on our website.

The six best policy management solutions in healthcare

  • PolicyStat offers a cloud-based platform to healthcare facilities, collecting all policies in one place, and streamlines policy creation, review, and approval. PolicyStat offers a compliance management tool that automatically notifies you when policies are about to expire and should be updated.
  • PolicyMedical is designed for healthcare, streamlining the workflows around policies. It lets you automate processes, such as automated alerts for outdated policies, version control, and or checking policies against the Joint Commission Standards.
  • MCN Healthcare is a healthcare policy management software that, as its name implies, is specifically focused on the medical field. Its software, Policy Manager, lets you control the workflow of policy creation, review, approval, and attestation. It offers real-time tracking and reporting of policies, search functions, and automated policy workflow. 
  • PolicyTech is a cloud-based policy and procedure management software created by NAVEX Global. It isn’t industry-specific, so it's more of a general solution. It focuses on increased efficiency in policy creation and updates and has the ability to produce audit-ready reports. You can also run checks to see whether employees have received and signed off on policies. And workflows help you track who has reviewed, approved, and rejected documents.
  • HealthStream Policy Manager (formerly ComplyALIGN) is a cloud-based platform designed specifically for healthcare. It is built for hospitals and medical care providers and has a simplified interface that lets you publish, access, and manage your policies and procedures. It features customizable document management workflow, shared review and approval, version control, auditing, and staff testing.
  • PowerDMS has policy and compliance management tools that help healthcare organizations create a living connection between policy, training, and accreditation. This saves you time and money when working toward accreditation and compliance. We serve more than 7,000 private and public sector organizations worldwide with secure, cloud-based solutions. We have an easy-to-use, modern interface and a robust mobile app, giving admins and users flexibility and convenience.

Of course, not all of these healthcare policy management solutions are created equally. Some are specific only to healthcare, some don't have a mobile app, and some don't offer testing or training. If you want to understand the differences between them, you can read more about the top six policy management solutions in healthcare. 

Final thoughts

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 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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