8 Suggestions to Maximize Risk Management Policies

Risk management professionals should not take lightly the complexity associated with providing healthcare services. While regulations, third-party payer requirements, and licensing/accreditation standards contribute to this complexity, formalized policies and procedures can mitigate it.

This article first appeared in PSQH Magazine.

Risk management professionals should not take lightly the complexity associated with providing healthcare services. While regulations, third-party payer requirements, and licensing/accreditation standards contribute to this complexity, formalized policies and procedures can mitigate it by promoting workplace safety, regulatory compliance, and the delivery of safe, high-quality patient care. Moreover, well-written, up-to-date policies and procedures reduce practice variability that my result in substandard care and patient harm.

The operational challenges associated with drafting (and maintaining) comprehensive written policies place heavy demands on healthcare managers. Given increasing financial pressures and the top-priority status that must be given to direct patient care, managers may find it difficult to find time to review or update policies and procedures. Deferring policy and procedure development, however, may result in negative consequences. Policies and procedures may become outdated, and those who adhere to outdated policies may carry out actions that are no longer consistent with industry-recognized practices. Alternatively, they may simply elect to disregard the policy. Either choice may result in patient harm and a malpractice claim. Evidence that caregivers followed outdated policies may hinder defense of an otherwise defensible claim.

Healthcare risk managers are encouraged to collaborate with other senior leaders in their organizations in order to maximize the usefulness of policies and procedures and reduce potential associated risks. The following strategies represent best practices observed by the author:

• Designate a senior leader to oversee policy development, approval, and periodic review by the appropriate policy owner(s). The Corporate Compliance Office and the Legal Department are well-suited for this responsibility since many policies pertain to regulations.
• Create a tracking mechanism that will identify when each policy’s periodic review is due, issuing advance notice to the policy owner in order to assure timely response.
• Issue policy development guidelines and train managers in their use.
• Create a system-level policy and procedure oversight committee with multidisciplinary membership and representatives from all entities. Consider forming domain-specific subcommittees for each department: nursing, pharmacy, biomedical engineering, etc.
• Incorporate training about policy and procedure compliance in new-employee orientation programs. Include discussion of each staff person’s duty to exercise judgment in specific situations and determine if any part of the policy or procedure warrants modification. In such circumstances, the staff member must understand the need to document the rationale for that decision—and the manner in which the procedure was modified—in the patient’s medical record.
• Hold managers accountable for policy development, review, and revision. Incorporate review of this responsibility into the annual performance appraisal process.
• Implement a feedback mechanism so staff can report situations to management that resulted in a near miss event or necessitated some form of workaround. Situations that prompt staff to use a workaround indicate possibly unreliable processes or practices. By reporting them to management, with the expectation that they will be investigated and addressed, the potential for patient harm may be reduced.
• Establish a committee to review the policies of any newly-acquired business units or practices and compare them to those already within the health system. Identify policy disparities and develop a plan for standardization, unless there are legitimate reasons why the system’s current policy needs to be modified in whole or in part, because of different jurisdictional statutes or different services offered by a particular organization.

The risks associated with writing, updating, and implementing policies and procedures are often under-appreciated by healthcare managers. Healthcare risk managers, particularly those shifting to an Enterprise Risk Management approach, may wish to draw upon the ideas in this article as they: a) collaborate with system leaders in developing “system-wide” policies and procedures (modified to meet a unique characteristic of a specific entity); b) meet with department or service line managers to identify optimal policy formats and content; and c) offer input to corporate leaders regarding policy review and updating practices.