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Risk and Policy Management

Risk and Policy Management


In healthcare organizations, the review and approval of policies are never at the top of the to-do list for the day, even though policies are often one the first things asked for by a regulatory surveyor. When there is the risk of litigation regarding patient care practices, it often gives rise to questions regarding organizational policy.  


We know there are many policy mandates by regulatory agencies such as CMS, TJC, DNV, etc. as well as recommendations as to who should be reviewing and approving policies and procedures. Regulatory agencies are purposeful and provide guidance in what best practices have shown to be effective in preventing risk to patient safety.  Ensuring the appropriate policies are in place is not enough.  A process that ensures evidence-based practice is integrated into policies; policies are reviewed and approved by leaders; and policies have been implemented and sustainable in practice are key to a high-reliability structure.  Not reviewing, approving, and sustaining appropriate policy management leads to risk.  How you ask?  


I frequently find during the evaluation of policy management practices, organizations have several vulnerabilities exposing them to risk.  Let’s take a moment to review just a couple of these.


The patient care associate’s inability to find an appropriate policy when clear direction is needed is a vulnerability.  This leads to workarounds and an organization’s deviation from standardized care as dictated by the policy.  Oftentimes staff do not access policies because of the cumbersome process of locating them at the point of care, leading to asking questions of co-workers and the possibility of getting the wrong advice, exposing the organization to risk.


Another policy management risk is allowing policies to expire.  This can be a difficult issue to defend in litigation cases, especially if those policies are specific to high-risk patient care areas.  If staff are following policies that have not been appropriately reviewed and approved in the established timeline, you run the risk that the standard practice may have changed, and your organization is not following best practice standards established by regulatory agencies.  


These are only a couple of issues related to policy management risk.  It would be to your organization’s benefit to perform a comprehensive preventive risk analysis to assist in identifying gaps in your organization’s policy management processes. 


An effective tool to assist in tackling policy management risk is the utilization of a software program that efficiently moves leaders through the actions of policy review and approval.  


Here are just a few key factors policy management software addresses to inhibit risk: 


  1. Notification of a required review of a policy by leaders when it is about to expire, enhancing efficiency and ensuring policies are up-to-date with evidence-based standard practice. 
  2. Provides a compliant alignment in the approval process of the leaders and subject matter experts required to review, revise, and approve a policy, ensuring evidence-based practice is available to staff to make the right patient care decisions 
  3. Organizes policies in an electronic manual to ensure multiple policies on the same subject are not available for use and thus potentially prevents a deviation from standardized care  
  4. Improves efficiency by providing resources of the latest information from regulatory agencies with the use of the Policy Library, decreasing the time and motion required to keep up with multiple changes in practice that occur daily by regulatory agencies   (Policy Library is available with MCN Healthcare’s Policy Manager)
  5. Provides easy access for users; promoting the use of policies at the point of care and limits the workarounds often seen by patient care associates.  


Effective policy management speaks to the efficiency and effectiveness of an organization’s culture in providing the best resources available to their staff and thus defines the expected platform for practice in a high-reliability organization.  A preventive risk analysis will expose issues in an organization when current policy practice is evaluated proactively.  Join me at ASHRM to discuss how to develop your preventive risk analysis and evaluate your policy management process to inhibit organizational risk. 


Would you like to discuss how effective policy management is a return on investment for your healthcare organization? Click here for a free, no-obligation Policy Manager demo!



Tina Nelson will be providing an educational course addressing policy management processes as a part of ASHRM Univerity in October 2020. Tina has 35 years of nursing and healthcare experience performing leadership roles in research, emergency and intensive care nursing, long term acute care, and behavioral health care.  For the past 20 years, she has specialized in post-marketing surveillance of new FDA approved cardiac biomarkers, quality and performance improvement, regulatory accreditation consulting, and content writing.  She has received numerous awards in innovative quality and performance excellence.  She has helped hospitals achieve success in regulatory and State certification, policy management, performance improvement, and, reversal of organizational conditional level findings and immediate jeopardy.





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