Importance of policies and procedures for hospitals

Access expert guidance on the role of hospital policies and procedures. PowerDMS empowers healthcare organizations to prioritize patient care and safety.

December 22, 2020

Article highlights

A good hospital runs like a well-oiled machine. From patient intake to output and billing and everything in between, all the pieces and processes work together to provide consistent, excellent care.

Of course, this can only happen if the hospital has all of those pieces and processes in place. Staff members must know what’s expected of them and have rules and procedures to guide their day-to-day tasks.

In a hospital, deviating from the rules and standards can be detrimental. Inconsistent practices will lower the quality of patient care, and could even harm the patient and put the hospital at risk.

This is what makes policies and procedures for hospitals so important.

Hospitals need good policies and procedures to function effectively and efficiently and keep both employees and patients safe.

What are the importance of hospital policies and procedures?

Day-to-day operations in hospitals are complex.

Between healthcare laws, accreditation requirements, licensing and certification standards, and more, hospitals must comply with many regulations and standards. Plus, doctors and nurses must communicate well and follow guidelines to ensure they are providing the patient with the care they need.

Hospital policies and procedures guide day to day operations and make sure everything is running as it is supposed to. They communicate expectations and standards to staff, set guidelines for operations and improvements, and streamline processes.

Patient safety

Policies and procedures for hospitals help hold employees accountable for following the right steps when caring for patients. They standardize practices across the organization and ensure that every patient receives the same level of care.

Standardized practices across the hospital keep patients safe. Policies and procedures for things like disinfection, charting, and medication help prevent common errors and illnesses.

Hospital policies and procedures also improve patient safety by helping guide decisions in critical moments.

Doctors and nurses don’t have to guess at what step to take or how to perform a procedure. This leads to fewer errors.

Improved internal communication and processes

A hospital employee may interact with dozens of patients and other staff members every day. As they hand off patient care to another doctor or nurse, communication is critical.

Policies and procedures for hospitals improve and streamline internal communication.

As we pointed out in our post about improving internal communication in healthcare:

Without effective communication, healthcare workers end up making decisions individually instead of as a team. This can be detrimental.

Studies have shown that roughly 85% of workplace errors are the result of communication failures.

On the other hand, good internal communication in healthcare fosters teamwork and collaboration.

Several studies have shown that good communication increases employee engagement and productivity. Effective internal communication ensures that every employee knows their role and responsibilities.

Reduced liability

Healthcare is inherently risky, and no hospital will be able to completely eliminate risks. However, well-managed hospital policies and procedures can help mitigate risks and protect hospitals from costly litigation.

Policies and procedures for hospitals reduce liability by creating an environment of consistent, high-quality care.

If an incident does occur, policies and procedures serve as evidence that the hospital has standards in place that comply with regulations.

Good policies and procedures can also help hospitals avoid False Claims Act, or Qui Tam lawsuits.

Policies that cover record-keeping, billing, and filing claims help employees comply with federal regulations and prevent fraud.


Simplified accreditation

Many hospitals choose to pursue healthcare accreditation as a way to strengthen their organization and gain a competitive advantage.

An accrediting body usually examines a hospital’s practices and policies to ensure they comply with certain standards.

So good hospital policies and procedures provide a strong foundation and make the accreditation process much easier and quicker.

This is especially true if the policies are housed in a searchable, accessible format such as a policy management software.

Types of Policies and Procedures for Hospitals

Hospital policies and procedures need to cover a vast array of practices – everything from prescribing medicine, to handling patient records, to visitation rules.

With policies in so many different areas, policies and procedures for hospitals need to be well organized and easily searchable.

They may be grouped into separate handbooks for different departments or roles. And though many of the policies will tie into others, it may be helpful to group them by type.

Here are some of the different types of policies every hospital should have in place:

Administrative policies

Hospital administrative policies cover the day-to-day business operations of the hospital. They help everything in the hospital run smoothly.

Administrative policies ensure that the hospital has the resources it needs to operate.

For example, these policies cover acquiring and maintaining equipment. They may also include policies on vendor requirements, licensing and credentials, and records requirements.


Patient care policies

Patient care policies and procedures for hospitals should be the most comprehensive set of policies. These policies are guidelines for how doctors and nurses care for patients.

Some of these policies are just procedural and tie in with administrative policies.

For example, patient admission and discharge, charting processes, and patient rights. But others are essential for patient and staff security, such as infection prevention, handling biohazard waste, disposal of needles, and so on.

While broad patient care policies should be consistent across the hospital, specific procedures may differ between departments.

The oncology wing, for example, will have a different set of procedures than the maternity wing.

Medicine policies

Studies have shown that medication mistakes are the most common type of medical error. While a patient is in the hospital, it’s up doctors and nurses to make sure they get the medicine they need.

If a patient is given the wrong prescription or dosage, it can be deadly. So medicine policies are especially important in hospitals.

Medicine policies help staff members keep track of prescriptions and dosage.

These policies include everything from paperwork requirements for medicine, inventory control, dose distribution systems, and disposing of expired drugs.

IT policies

As medical records have turned digital, data security has become vital to hospitals.

Hospital computers and drives contain sensitive patient information. And HIPAA requires hospitals to keep that information secure.

IT policies and procedures for hospitals should set up strict safeguards on all IT systems.

Hospitals should regularly update these policies to ensure HIPAA compliance, and have strict policies in place for everyone who interacts with sensitive information.

HR policies

A hospital can only provide good patient care if managers and administrators are caring well for employees.

Employees are a critical part of operations, so keeping them healthy, safe, and happy is an important part of a successful hospital.

HR policies govern the management of internal personnel. They make sure hospital staff know basic expectations such as how to dress and how to clock in and out of work.

HR policies and procedures for hospitals may be fairly similar to HR policies in other industries. They cover thing such as vacation days, social media use, shift policies, and more.

How to manage your hospital’s policies and procedures manual

Policies and procedures for hospitals should be more than just theoretical guidelines. And they should be more than a set of rules that sits forgotten on a shelf somewhere in the hospital office.

With so many moving pieces and changing regulations, it’s essential for hospitals to effectively manage their policy manuals.

This includes regularly updating policies, distributing them to staff, and making sure they get implemented across the organization.

Learn more about healthcare policy and procedure management in this helpful guide.

Make it digital

Paper training manuals are largely a thing of the past. Hospital staff are constantly on the go, so they need a policy manual that can keep up.

A policy management software stores all hospital policies and procedures in one central, secure location.

The software makes it easy for hospital employees to access the policy they need. They can simply log in from any mobile device and do a keyword search.

Digital policies are also much easier to organize and update. Hospital administrators can collaborate on policy updates and distribute new policies to employees with just the click of a button.

Review and update your policies regularly

With healthcare laws and regulations constantly changing, hospitals need to make sure to regularly update policies and procedures.

Even in areas where regulations don’t change, hospital administrators should try to review policies at least annually.

Regular policy review is also an important part of most accreditation processes. Accrediting bodies need to see that hospitals are reviewing and maintaining policies to keep up with current technology and best practices.

Good policy management also shows employees that policies truly matter.

As staff see the policies being cared for and regularly updated with the latest best practices, they understand the importance of the policies from the top down.

Regular policy updates set the expectation that staff will refer back to policies instead of ignoring them as other habits and routines take over.

In the process of reviewing and updating policies and procedures, hospital administrators may ask for feedback from staff.

Creating a culture of open communication can help administrators spot gaps in policy. It will also build trust with employees when they see their suggestions are taken seriously.


Develop an implementation and training plan

Policies and procedures for hospitals do no good if no one sees them. Hospital administrators need to distribute policies to every staff member and make sure they read and comprehend them.

And this shouldn’t just happen during the onboarding process.

Staff members need to be made aware of new policies and shown what has and hasn’t changed in updated policies.

In some cases, new or updated policies may come paired with training or testing to ensure employees comprehend the changes.

A good policy management software can help administrators easily distribute policy updates to all employees.

Software such as PowerDMS can also gather policy sign-offs, distribute online training, and help administrators create quizzes to test understanding.

Well-managed policies and procedures are an essential part of any hospital. Hospital policies and procedures keep patients and staff safe, lay the groundwork for high-quality care, and ensure that operations run smoothly.

As you seek to create comprehensive policies and procedures for your organization, use a policy management software to keep your policies organized, up-to-date, and accessible.

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