When asked about the critical components of an effective risk control process, most CEOs will cite a hospital’s policies and procedures. Regulators and accrediting organizations such as the Joint Commission agree; and rely on a hospital’s policies and procedures in their assessments. Most hospitals, therefore, dedicate significant resources to developing, updating and communicating policies and procedures to staff.
In many cases, the CEOs are, however, unaware of the extent of their hospital’s resource investment in developing and updating policies and procedures. Why is this? Frequently responsibility for policies and procedures is absorbed by multiple resources having other unrelated responsibilities. The time dedicated to policies and procedures is usually not discretely tracked.
When staff is faced with multiple priorities, policies and procedures frequently become low priority activities. The hospital then lags in updating policies and procedures and becomes exposed to the risks of non-compliance with governing requirements. Joint Commission surveys become crises with staff scrambling to update policies and procedures and align practices with requirements.
This paper focuses on the practices best-in-class hospitals have adopted for effectively managing policies and procedures. These practices provide high value benefits to hospitals:
- Enable the hospital to be constantly ready for surveys and audit
- Reduce the risk of staff non-compliance with governing requirements leading to fines and potential reductions in revenue and loss of accreditation.
- Improve staff productivity