What exactly is policy and procedure management? Simply put it’s the process of creating, communicating, and maintaining policies and procedures within an organization. A typical healthcare organization has numerous policies on a variety of topics related to patient care, so having an effective policy and procedure management system in place is critical. A comprehensive and well-managed set of policies can support a healthcare organization’s activities by communicating boundaries and expectations, establishing a culture of compliance within the organization, protecting the organization from litigation and helping provide the best possible care to patients. It is a critical component of care in any healthcare institution. To help you in your policy management efforts, we have put together a list of best practices that can help support effective and efficient policy management.   

Find A Policy Administrator 

This is key. A policy administrator is the person who will be the resident expert for your policy management system. This could be either a full or part-time position based on the needs of the organization and can be sourced internally or externally. When hiring internally, healthcare organizations typically find a strong candidate within its administration, quality or compliance departments. A policy administrator’s responsibilities include maintaining and distributing policies, procedures and forms, providing training and compiling policy data. 

Create A Policy Committee 

Time to rally the troops. Assembling a policy committee is an important best practice that will help keep your policy initiatives on track, policies up to date and your organization in compliance with regulatory agencies. Policy committees allow for centralization of thought and open communication about your policy and procedure management process. The committee should consist of key stakeholders from various departments, including nursing, quality, administration, education and IT. At a minimum, you should meet once per quarter. Try to avoid scheduling meetings more than once a week, if possible. Policy committee meetings should be tactical in nature and have a clear agenda outlined before each session. 

Standardize Your Policy Format 

Consistency is your best friend. Policy standardization should be a major priority for healthcare organizations. Organizational changes, including mergers and regulatory changes, can lead to inconsistent policy formats. It is best to achieve a consistent look and feel for your policies, with a corporate logo, an appropriate legal disclaimer and the inclusion of all key policy sections. RLDatix PolicyStat converts all policy documents into web pages and standardizes their content to achieve a consistent format across the entire policy library. When policy content is standardized across an organization, all staff can easily locate information at the point of care. 

Create a Policy on Policies 

Set the standard. Creating a policy on policies is an important step to having an organized and efficient policy library. Your policy on policies will set the process for drafting, reviewing and approving all organizational policies. It should be written with regulations and standards, organizational norms and expectations and your policy management system in mind. 

Delegate Responsibilities and Control Access 

Establish a workflow. Your policy management system should allow you to delegate responsibilities to specific individuals such as writing, editing, reviewing and approving policies. Establishing committees and workflows will standardize the way a policy is revised each time. PolicyStat supports robust workflows and archiving functionality, helping organizations know the status of every policy in their library. Your administrators should also have full control over granting users (or groups of users) different levels of access for reading and editing policies, thus maintaining overall security and privacy. Keeping policies up-to-date and easy to access by staff helps reduce organizational risk. PolicyStat allows organizations to manage policy reviews, make edits to policies and set up approval workflows all from one centralized system. While some policies require annual reviews, other policies’ review dates will require updates depending on organizational changes. PolicyStat enables scheduled reviews, such as an annual review of the organization's code of conduct, as well as ad-hoc reviews that might arise depending on an organization’s current needs.  

Track All Policy Changes – When, Why and by Whom 

Create accountability. A clear trail of policy changes is imperative when questions or disputes arise relating to compliance. An effective policy management system should track all changes and record who made each change, when it was made and why. Your policy management system should automatically notify the appropriate individuals when policies are up for review and archive previous versions. PolicyStat allows staff to track their changes directly in the software, allowing all editors to easily see the progress made on a policy. To promote clear communication across an organization, PolicyStat also allows provides notifications regarding policy changes and acknowledgement reminders.  

An efficient approach to policy and procedure management should provide