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Like it or Not, a Review of Your Organization's Policies & Procedures is a Priority

Apr 16, 2021 12:30:00 PM

When was the last time you audited your policies and procedures? Ensuring they are accurate and current is one of the less glamorous facets of any healthcare organization. However, they also communicate to staff, regulatory entities, and potential auditors about how your organization functions.

10 Helpful Tips To Make The Most Of Your Review Of Policies, Procedures

This can be daunting, even with technological advances and adequate staff assigned to the task. But before getting started, the Compliance Department at InSync Healthcare Solutions would like to offer some tips to help tackle this important subject:

  • Create a policy about your policies. This sounds redundant, but it is far from it. This policy-on-policy can 1) lay the groundwork and expectations for what is contained in a policy, 2) determine how frequently it is updated, 3) who reviews it, 4) what the format is, and 5) provide other details that will help standardize the look and feel of your documents. Adding a section that lists any regulatory citations can be a timesaver in the event of an audit or credentialing review.

  • Create a table of your policy information in a database system, like Excel. List the policy number, name, when it was enacted, when it was last updated, and who owns this policy. Policy numbers (like Admin 101) help track and catalog your policies with ease. Once you create your table you can also identify what is missing from your dossier of policies.

  • Prioritize your policy review. Identify crucial policies that require review and potential updates as well as documents that might need to be created. Spreading out policy reviews over a period of time can help make the task less daunting. Do not set yourself up for failure by trying to get through 30 policies in a weekend.

  • Understand there are no shortcuts for the actual reading of the policy content. Make content changes to help future reviews easier. Policies that contain detailed procedures that are subject to frequent changes can be edited out – move the procedure to your standard operating procedures (SOPs) and update the policy to direct the reader to the SOPs. Consider removing legal jargon or lengthy regulatory sections and replacing them with clear language.

  • Think about the length of a policy. If a policy is very long, it could potentially include information already present in another policy or in a SOP, contain screenshots or a large amount of regulatory information that was directly copied and pasted from a source.

  • Ensure no PHI is in a policy or procedure. If you have an SOP for a software program that includes screenshots, then Personal Health Information can easily get in places it should not, which eventually could lead to it being disposed of incorrectly.

  • Streamline with flowcharts: If you need to include a process or procedure in a policy, consider using a flowchart instead of typing out the steps. Flowcharts can be quickly updated, utilized as SOPs, and often help identify internal redundancies or workflow bottlenecks.

  • Consider removing any individual staff names in a policy. If the policy states, “Betty handles this” but Betty no longer works at the office, the policy is outdated and immaterial. Instead, replace names of people with titles, such as,  “The Director of Nursing is responsible for this”.

  • Ensure that you are doing what your policies and procedures say you do. This may seem silly to say, but it is a red flag for auditors or regulatory entities. Policies and procedures need to match the actual activities in the organization, not the desired future state.

  • Review changes. After making edits, ask someone in your organization to read the policy and ask, “Does this make sense?” If your staff doesn't understand the policy or procedure, they will not be able to communicate or perform effectively with your valued patients.

Make Your Practice The Best It Can Be

Policy audits are time-consuming but required for effective practice management, regulatory compliance, and patient safety. Streamlining your policies and adopting easy-to-update SOPs can make the process and your organization stronger.

Another way to make your practice stronger is with mobile-friendly, fully integrated EHR software from InSync Healthcare Solutions.

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For a closer look at how our software system can increase your organization's efficiencies, please schedule a demo now with one of our experts who'd be happy to explain how it works and answer any questions you might have. 

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Beth Socoski

Written by Beth Socoski

With more than 20 years of experience in healthcare, compliance, and security, Beth brings integrity, respect, and a world of valuable and applicable knowledge to the InSync team. In addition to three master’s degrees, she has multiple accreditations in healthcare, compliance, ethics, and leadership. As a scholar at heart, she is steadfast in her desire to remain current on compliance requirements – and to share that information in language that is easily understood by all.

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