Compliance Policy Management: A Comprehensive Guide for Healthcare Leaders
The average U.S. healthcare company is subject to 629 regulatory requirements across nine distinct domains.1 But how can you ensure the policies and procedures you implement cover all that ground without creating an unmanageable burden for your team? The answer lies in proactive compliance policy management. This article explores everything you need to know and do to simplify and enhance your compliance program.
What is Compliance Policy Management?
Compliance policy management is the process of creating, implementing, evaluating, and maintaining compliance policies and procedures. Rather than simply “setting and forgetting” internal processes, a policy management program helps organizations take a proactive stance toward compliance and delivers several clear benefits:
- Up-to-Date Processes: Regulatory updates, such as the upcoming changes to the HIPAA Security Rule, must be reflected in an organization’s compliance policies. Compliance policy management makes adapting to regulatory changes smoother and more proactive.
- Improved Adherence: Many organizations struggle to ensure their employees follow compliance processes, often due to a lack of clarity within the written policies. Policy management helps to identify and resolve these issues to improve adherence and overall compliance posture.
- Reduce Workload: While proactive policy management may appear to be extra work upfront, it ultimately reduces your compliance team’s total workload over time. Issues such as locating policies, identifying gaps in compliance, and implementing new policies become far easier when you have an official set of processes.
Achieving these benefits depends on optimized processes across several key areas, which we can now explore in detail.
Policy Development: How to Establish Core Compliance Processes
Our experience working with countless healthcare compliance teams suggests that four key steps are required to develop effective compliance policies and procedures:
- Understand the Regulatory Environment: Begin by thoroughly evaluating the specific legal requirements applicable to your organization. Follow guidelines from authoritative bodies such as the Department of Health and Human Services (HHS), Joint Commission, and state health departments.
- Engage Stakeholders: Make sure all key stakeholders, including legal advisors and department heads, are involved in the policy development process. Their input ensures a comprehensive understanding of the practical and operational impacts of the policies.
- Conduct a Risk Assessment: Evaluate potential compliance risks unique to your organization. Ongoing risk assessments will guide you in prioritizing areas of focus and developing relevant policies to mitigate these risks.
- Develop Clear and Concise Policies: Write policies that are easy to understand and simple to apply. Avoid jargon and ensure the policies clearly outline the rules, responsibilities, and procedures to be followed.
However, effective policies are not only thoroughly researched and well-written, but also documented in the best possible manner.
Best Practices to Improve Policy Documentation
The following steps will ensure your policies are easy to find, follow, and adjust:
- Use a Standardized Format: Ensure consistency in how policies are documented. Best practices include using a standard format with sections such as purpose, scope, definitions, policy details, procedures, and responsibilities. Such a structure makes it easier for multiple stakeholders to understand policies, as well as ensure changes in staff do not lead to confusion or “information leakage.”
- Implement Version Control: Maintain version control on each document, allowing you to view and compare changes with earlier versions of the policy. Clearly annotate updates in policy and the rationale behind them. This ensures your team can quickly identify errors, as well as provide evidence of proactive efforts to improve compliance for future regulatory reporting.
- Record Authorization and Approval: Document the approval process for each policy, including the identity of the person or committee that authorizes and approves it.
Policy Implementation: How to Drive Ongoing Compliance
Policy managers must turn plans into action, and that requires ongoing efforts to increase adoption and adherence to core compliance policies. Our team has identified three important steps that can dramatically improve ongoing policy adherence:
- Eliminate Ambiguity: Compliance policies must be clear, yet many smaller organizations consolidate their policy lists for the sake of efficiency. This approach can make it harder for employees to understand and follow procedures, leading to lower adherence and, ultimately, higher compliance risk.
- Centralize Policy Access: Keep all policies in a centralized digital repository accessible to all employees and actively promote their availability through internal communication channels. This helps ensure everyone is aware of the most current policies and procedures.
- Evaluate Efficacy: Run assessments to understand how your employees feel about compliance and how well they understand your current policies and procedures. This can be done through internal measures, but many organizations benefit from working with a third party that can offer an external perspective on compliance program efficacy.
Policy Revision: How to Adapt Your Compliance Program
The process of revising key policies will always be context-dependent, with the scope and urgency of changes dictated by the evolving regulatory landscape. However, there are still two key factors all policy management programs should consider:
- Regulatory Trends: Don’t simply chase the latest HIPAA updates – actively assess and adapt to trends in regulatory activity before they become law. For example, organizations outside New York can learn a lot about future healthcare data privacy requirements by studying the state’s recent Health Information Privacy Act, which signals the direction other states are likely to take in the coming years.
- User Friendliness: As our recent article explains, the U.S. Sentencing Commission, the Department of Justice, and the Office of Inspector General all emphasize the importance of policies that provide clear guidance for non-experts. Policy revision should always aim to increase clarity and provide concrete, actionable steps.
Revising your policies can be a time-consuming and stressful experience, especially when your team is always busy. Many organizations never find the time to properly overhaul or improve their procedures, leading to a slow increase in non-compliance risk.
Strategic Management Services helps combat that problem. Our expert team reduces the burden on your compliance team and makes policy management seamless, with everything from policy development services to Compliance Program Effectiveness Evaluations.
Want to instantly take the pressure off your team’s shoulders?
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