Hospitals deal with numerous requirements from local, state and national regulatory bodies. These requirements set the standards for what is acceptable and unacceptable, while also giving hospitals valuable credentials and instilling a sense of trust with patients and the wider community.
The Joint Commission, HIPAA and CMS, among others, set and enforce standards hospitals must comply with. Non-compliance with these regulatory bodies can lead to a loss of accreditation, fines, criminal and civil action, and compromised patient safety to name just a few. A well-managed set of policies can aid a hospital in creating and maintaining policies that keep them up to date on these requirements and in compliance with relevant bodies.
Here are five ways policy management will help your hospital improve compliance.
1. Track employee comprehension of new and updated policies
One of the most important ways a policy management system can help your organization achieve compliance is by tracking which policies each of your employees has read, when they read it and whether or not they understood it. An attestation feature in your policy management system, or the ability to link your policy management system with a learning management system, is important. These features give you the ability to provide additional resources and quizzes to staff members to ensure they have fully understood the policies they have received. The following example illustrates this:
The education lead at a large, multisite hospital needs to know if all staff members have read the updated policy on the prevention of nosocomial infections. She runs a report and determines all employees have read the new policy, but only 20 percent of them passed the accompanying quiz. She decides to plan some additional training and education sessions surrounding the policy.
2. Avoid litigation and potential criminal action
A policy management system helps hospitals avoid costly litigation by preventing risk and creating paper trails. All regulatory bodies require formal documents that can be provided as evidence of a hospital's policies and procedures, employees' knowledge of these policies and procedures, and patients' awareness and agreement with them. Additionally, just having a set of documents is not enough. In the case of litigation, the hospital must be able to find the documents easily and have a record that they were read and understood. An efficient policy management system can create the necessary paper trail to avoid litigation, and support you just in case it does litigation does happen.
3. Deliver detailed reporting in real time
In hospitals, information is vital. In regards to hospital policy management, this information could include utilization of the system, progress of policy updates, and attainment of long-term education and compliance goals. This information should always be up to date and available instantaneously. Nursing leaders, IT staff and policy administrators are often the employees that run reports to provide to CEOs and other high-level hospital administrators for decision-making. An efficient policy management system will store a great deal of data that can be compiled and analyzed regularly. For instance, if a policy administrator needs to know how many policies are up to date, and how many are past a due date, she can run a real-time report that will give her this information. With this information, the department heads can decide to allocate additional personnel resources to work on policies. Real time reporting is an indispensable tool in a hospital's policy management system.
4. Reduce operational inefficiencies and subsequent costs
A policy management system also eliminates excess costs associated with copying, distribution, organization and storage of policies, as well as the time spent doing so. Nursing leaders, IT staff and policy administrators no longer have to spend time on the paper shuffle associated with manual policy management. An efficient policy management system can automatically notify you when policies are out of date, or when they no longer meet regulatory requirements. From there, the entire policy revision, review and approval process can be carried out seamlessly, right within the policy management system. Time and resources can be reallocated to bigger picture planning to reach compliance goals.
5. Prepare for audit
Auditors from regulatory bodies often show up with short notice, and stay on site for several days. Preparing for audits can be an overwhelming and time consuming process. During an audit, the auditor will request a great deal of documentation from hospital staff. The most important preparatory step for the hospital is to maintain up-to-date documentation of policies and procedures. With a policy management system, this is much more manageable. A policy management system that is well organized and searchable allows specific policies to be pulled up quickly and easily. In addition, a policy management system can link policies and procedures to relevant regulations, demonstrating the hospital's compliance instantaneously.
Policy management guru Michael Rasmussen, defines compliance as adhering to stated requirements, while establishing the values, ethics, commitments and social responsibility of the organization. Compliance is not a series of activities, but rather, an organizational culture. Also an efficient policy management system can support your hospital's shift toward maintaining this culture. In today's healthcare environment, things are constantly changing, and hospital employees are required to do more with less. Policy management activities can easily become low priorities. With an efficient policy management system, employee comprehension can be easily tracked and reported, cost and risk are reduced, and your hospital can stay audit ready. Thus, your culture of compliance is easily maintained.
About the author
Saud Juman is CEO and founder of PolicyMedical, which provides Policy Management, Contracts Management and Business Associate Management software, and support, for the healthcare industry in North America. He can be reached at sjuman@policymedical.com