Hospital Policy Management – Policy Archives and Good Recordkeeping

Managing policies and procedures in hospitals is a huge task. We often see small critical access hospitals that have upwards of 1,000 hospital-wide policies in circulation. And the number only increases with the size of an organization. If you take this number and multiply it by the number of departments or individuals that both write and are required to review and have access to the final versions of the documents, the task of keeping it all organized is quite daunting. Therefore it is not surprising the first thing hospital administrators are looking for in a policy management system is the ability to manage the review process and provide easy access to current versions of policies to the staff. A feature that is often overlooked is a solid revision tracking and archival engine.

A few years back we worked with a small hospital that had recently lost a malpractice lawsuit. It was not because the clinical staff was charged of any wrongdoing, but rather because the organization wasn’t able to prove when a specific procedure was put in place and made accessible to the clinical staff. As one can imagine, the actual cost affiliated with fines and repercussions of the lawsuit, especially given a small and tight rural community where the hospital was located, were enormous.

Unfortunately similar stories are not that uncommon. Given the strict regulations both from state as well as other accreditation bodies such as CMS or Joint Commission, proper record keeping and revision tracking for hospital policies and procedures should be considered as important as keeping track of a patient’s care history. Anyone that has been deeply entrenched in policy and procedure management could name numerous specific pieces of information that need to be retained with each version or revision of a hospital policy.

In general, a policy management system, whether manual or computerized, should allow for providing the following information:

• A read only copy of an actual document that was published
• Dates when a specific document was in effect and accessible to staff
• Dates when each version of a policy was approved, published, and revised or archived
• Any supporting documents, such as a redline version of the policy that was used during the approval process
• Name of the authors of the document
• Names of document approvers and dates when the document was reviewed and approved by these individuals
• Records of when staff reviewed and acknowledged reading required policies

And as with any process, it is typically much easier to build small record keeping steps into your current workflow that record collaboration as your documents flow thru the revision cycle, rather than track down this information later when much of it may be missing. Proactively putting these measures in place can save your hospital almost immeasurable scrutiny later.

For more information on policies and procedures, download our free eBook, 5 Best Practices For Managing Policies in a Healthcare Environment.