Overwhelmed with Lab Policy Management Requirements?


describe the imagePolicy management in the highly-regulated healthcare environment requires stringent standards to be met. Many in healthcare find themselves jumping through ever-changing hoops to accommodate new mandates. Labs in particular have exceptionally high standards to meet in order to comply with CAP and CLIA requirements.

Aside from requirements around access to Policies and Procedures and mandates that what resides in the Policies and Procedures matches what is actually taking place in labs, the ability to document each staff member having read documents is the sort of thing that keeps lab directors up at night.

For example, this note included in a CAP update regarding changes to Policy and Procedure review requirements, lab managers are faced with some requirements that have been eased alongside some that have been made more stringent:

” The director must ensure that the collection of policies and technical protocols is complete, current, and has been thoroughly reviewed by a knowledgeable person. Technical approaches must be scientifically valid and clinically relevant. To minimize the burden on the laboratory and reviewer(s), it is suggested that a schedule be developed whereby roughly 1/24th of all procedures are reviewed monthly. Paper/electronic signature review must be at the level of each procedure, or as multiple signatures on a listing of named procedures. A single signature on a Title Page or Index of all procedures is not sufficient documentation that each procedure has been carefully reviewed. Signature or initials on each page of a procedure is not required.”

Meanwhile CLIA standard for Procedure manuals laid out in Sec. 493.1251 outline very granular and specific requirements. Even a casual perusal of these tandem requirements makes one wonder how any lab director was able to meet all these requirements before the days of Policy Management Automation.

At HospitalPortal, we have experienced an influx in interest in our Policy Manager by labs specifically over the last few years. In several cases, the labs have been gripped with a sense of urgency in getting their arms around policy management to the extent they have opted to automate policy management just for the lab, concerned about waiting for agreement to move forward from rest of the hospital.

To support this growing niche interest by labs, we have dedicated our upcoming session in our Educational Webinar Series to Policy Management in Labs. The session will take place Wednesday, March 20 at 10:30am CST. We invite you or you lab colleagues to join us.

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