Pitfalls of Policy Management

Policies are the foundation of a health center’s operations and provide a framework to outline the organization’s position regarding a particular subject and/or issue.   Policies are considered the “rules” that govern the organization, while “procedures” outline the steps to ensure compliance with the policy. 

One of the key issues with policy development and implementation relates to the manner in which policies are managed.  Various methods can be used, although it is important to manage policies in a way that is most appropriate for the size and complexity of the organization, while still supporting compliance with State and Federal Regulations.  Some factors to consider when selecting a process to manage policies include:

  • How frequently are policies reviewed and updated?
  • What is the volume of policies?
  • Are all policies presented to the Board of Directors for approval, or just those required by the Health Resources and Services Administration (HRSA)?
  • Is the health center in a financial position to purchase policy management software?
  • Who will be the “keeper” of the policies?
  • How are staff trained on policies?

Once a process is implemented, it is important to avoid some common mistakes that can not only impact compliance, but also impact the standardized delivery of quality patient care.  Some common practices that can help to avoid pitfalls with the policy management process include the following:

  • Determine which policies will be Board approved.  Policies requiring Board approval to ensure compliance with HRSA Health Center Program Requirements are outlined in the HRSA Health Center Compliance Manual (Health Center Program Compliance Manual).
  • Develop a calendar for the approval of policies, to avoid overloading staff and Board Members.
  • Whether using paper manuals or an electronic system, identify one or two “point persons” to manage policies.  This will ensure all staff have the most up to date version and all other versions are replaced.  
  • Attempt to consolidate policies as much as possible.  For example, avoid developing a separate policy for the Contents of Credentialing Files, Modification/Revocation of Privileges, and Temporary Privileges.  Streamline the process and address all the requirements in a single policy.  Not doing so opens opportunities for non-compliance.  
  • Determine how staff will be trained.  The health center can have industry standard policies, although they will not be beneficial if the education of staff does not occur. 

Additional resources for policy development, implementation and management can be found at (ECRI | Trusted Voice in Healthcare)

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