Signs your Hospital’s Policies and Procedures Management Need a Facelift

Many hospitals still utilize manual processes to manage and distribute changes to internal forms, policies and procedures. These critical hospital documents need to undergo periodic reviews and revisions. Detailed approval records need to be stored along with each revision to meet various compliance requirements or regulations. As a result, many healthcare organizations often find themselves looking for a better method for managing and distributing updates to these documents. Unfortunately, since Meaningful Use has everyone focusing on EMR implementation projects, automation of administrative functions such as policies and procedures management quite often do not get the leadership’s attention as they deserve. However, as the number of revisions and policies continues to grow, the supporting management processes can get easily out of hand.

Here are some sure signs the policy and procedure management process in your hospital should be brought back to the top of the organization’s priority lists.

1. Outdated copies of policies still in circulation.

   – The staff needs to be sure a policy, procedure, protocol, form, or a standing order they are viewing represents the most current and updated version. An updated policy that hasn’t been properly published will result in the same negative outcome as a policy that hasn’t been updated at all. The policy and procedure management process needs to ensure that every time a new version of a policy is created and published, the old version is properly removed and archived.

2. This policy was last revised a century ago…

   – It is not uncommon to see policies or other critical documents that haven’t been reviewed for many years somehow fall thru the cracks. Without a centralized reporting mechanism it is often difficult to spot such documents. A robust policy and procedure management system should allow users to easily identify outdated documents and implement an ongoing review process with auto-generated alert mechanisms.

3. Where is that procedure?

   – A policy and procedure management system is not just about management and review of documents. A complete process should also include an integrated browse and search function for all published copies of documents so everyone that needs such access can easily search based on keywords, titles, etc. Having a separate “publishing” process from the approval process invites opportunities for mistakes, increased human-errors, and missed documents.

4. Approvals and signatures tracked on paper or communicated via snail mail and email.

   –It is not uncommon to have sequence of approvals or approval committees that need to be properly assigned to any given policy, procedure or form. Under normal circumstances it may be possible to track the status of each document on paper or in an Excel spreadsheet and communicate approval requests via email. However, once a document is rejected and requires a set of revisions to be made by its authors, and consequently resubmission for approvals, very quickly the status of the document, approval notes and approval information can get out of hand. A comprehensive policy management process should fully automate approvals handling and make it clear to policy administrators and all involved approvers, where the document is in the approval process. This includes triggering automated alerts to approvers when their actions are required.

5. Impossible to locate a version of a document that was in use on a specific date?

   – Your hospital’s quality, compliance or legal departments may need a version of a policy, procedure or a form that was in use on a specific date. Whether as a result of an internal audit or a potentially expensive malpractice lawsuit, it is expected these types of requests may come up from time to time. A robust policy management system should not only allow to easily locate specific policies or all policies that were in use on a specific date, but it should also be able to produce a full audit trail and approval report for that version of a document.

6. No one is aware of changes to critical policies or protocols.

   – A policy and procedure process should ensure key staff is aware of updates and changes to your hospital’s policies and procedures. It should ensure that the right people are notified when a key new policy is published or an existing important policy is revised.

7. So how many policies and procedures do we have?

   – This is a quick test to see how comprehensive and robust your current P&P process is. Can you tell how many documents there are? If you can’t answer this basic question, how can you be sure you are not missing any policies or procedures that need to be tracked?

8. It is Impossible or difficult to transition approval responsibilities to new managers.

   – An effective policy management process should make it easy to transition a portion or all policy management or approval responsibilities between staff.

9. Same policy, many departments, and multiple versions.

   – It is not uncommon to have the same or similar policy, procedure or form accessible by more than one area or department. A key feature of a robust policy management solution is the ability to manage a shared documents across multiple sections of the policies repository without having to individually track changes, approvals and revisions separately for each copy of same policy or procedure.

10. Joint Commission / CMS failing grades.

    – One area many accreditations and regulatory bodies closely review during audits is hospital policies and procedures. Auditors are looking for well managed policy and procedures processes that ensure the organization follows regulations and guidelines required to meet their accreditation standards. Getting a failing grade from an audit can result in a very costly outcome to a hospital. A modern policy and procedure management solution can easily address most key review components with its built-in, out-of-the-box, automated functionality.

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