for DR.SAMULESON only!!!!

MHCM 6320 Corporate Compliance and Legal Issues in Healthcare

Chapter 8 Creating Policies and Procedures

Chapter 9 Education and Training

Week 6 Lecture Notes

We have been considering the effect of the application of various laws and regulations

that affect health care providers of all sizes and scopes. All of these providers have a

common need for the organizational structure that good policies and procedures

provide.

Any good policy must contain certain basic elements and to assure this content, the use

of a template is a good process. Such a template should include the policy type, its

rationale, the population to be affected, and how to comply. It should also include a

specification of the preferred and contingency behaviors, and oversight responsibilities.

It should also set out the times for review and update of the policy and the

consequences for non-compliance, both those to be applied within the facility as well as

those likely to be the consequence from the government.

Considering each of these elements in more detail, the policy manual must include

every element of required and expected actions and such topics must be listed. Not

any single policy will cover every possible situation, even within the boundaries of a

single department. So, the first step is identification of issues that require policy

declarations. In identifying issues, no assumptions should be made that others have

the same or even a similar perspective to your own. And, it is important that the named

policy be enforceable.

There is an extensive list of possible policy subjects in the Text in Chapter 8. This list

can be used as a basis for the development of a more specific, tailored list in policy

development.

In developing and stating a policy rationale, attachment to the specific organization is

vital, so that the importance may be understood. Unless the policy is thought to be

important to the success of the organization, it will be difficult to attract the necessary

attention to its requirements.

Likewise, the application of the policy to particular individuals within the organization is

necessary to both assure the attention of those affected and to relieve those that are not

affected from its additional responsibilities.

The policy must clearly state what behavior is required by its terms, as well as what

contingency behavior is applicable when the primary behavior is impossible to meet.

In order that such behaviors are understood and carried out, there must be a clear

description of the preferred behavior, with substantial detail as to steps to be taken. At

the same time, the contingency behavior must be spelled out in such a way as to

demonstrate an understanding that real world situations often require alternative

actions.

It is necessary that oversight be clearly and firmly established in one person or category

of persons by job title.

Likewise, a process for policy review and update, including procedures for employee

input and criticism should be established and published, along with a publication of the

consequences for non-compliance with established policies. Both facility and

government penalties should be inherent in the publication of policies and should be

reinforced by the person/s with oversight authority/responsibility.

All of this information should be contained within a Policies and Procedural Manual.

Such a Manual, to be effective, must be published and constantly referred to and

updated so that it is a “living” document. There is nothing more useless than a

wonderful Policies and Procedures Manual that has been developed, published, and

placed on a shelf to gather dust.

This Manual, when properly developed and published, can become a primary source for

education and training of staff. In addition, the training and education of staff can be a

rich source for the purpose of revising and updating the policies and procedures

contained within it.

No business should assume that its employees, whether they come fresh from a formal

education or from some or extensive experience within the industry, are well trained and

ready to assume full and effective responsibility for carrying out the work of the current

provider organization. A well designed training program is the best insurance against

such bad assumptions.

Such a training program must first consider the what, who, when, how, why and where

of content. The what is the question of what topics to be covered, the who is the

determination of particular personnel to attend a particular session for training, and the

when answers the question of scheduling. The how, is the definition of the process and

time to be spent in a particular training program including the number of sessions, as

well as determination of the methodology to be used in the sessions. The why explains

the value of the training to its participants, while the where is locating the training

activities.

Included in the training must be a repetition of the requirement for reporting non-

compliance. This is repeated because of its importance as well as because of the

natural resistance in our culture of “spying or tattling”. While we have learned to avoid

these practices as a cultural norm from childhood, the training, as well as the everyday

actions must reinforce the differences in non-compliance reporting and these

objectionable practices.