Chief Compliance and Ethics Officer Health Care

 View Only
  • 1.  Policy on Policy

    Posted 06-28-2022 08:29 AM
    Hi everyone,

    Would anyone be willing to share their policy that discusses their organization's management of policies? I'm hoping to gather ideas for such areas as how frequently policies must be reviewed by their respective authors and what happens to a policy when it hasn't been reviewed within the given timeframe. I'm thinking that the policy should be retired (so the agency doesn't wind up with a policy in place that isn't being followed) and can be reinstated once the author reviews/revises and it's accepted/approved by the Policy Committee. There are a lot of other areas I'd like to formalize as well and would love to see what other organizations are using.

    Thanks in advance!

    ------------------------------
    Chris Ambrose, MBA, CHC, CHPC
    Compliance Officer
    Service Access and Management, Inc.
    Lewisburg, PA
    ------------------------------
    Default Blank


  • 2.  RE: Policy on Policy

    Posted 06-28-2022 08:49 AM
    Hi Chris,

    Thanks for your discussion prompt! From the land of higher education here are two institutional links that you might find helpful even if they are cross-sector (they include information such as review cycle, templates, governance structure, and a reporting function). Based on your organizational context are these helpful?

    https://www.ucop.edu/ethics-compliance-audit-services/policy/policy-development/update-policy.html

    https://policy.umn.edu/operations/upolicy-proc03

    Thanks!

    ------------------------------
    Stephen (Steve) Pavlicek | Community Engagement Manager
    Society of Corporate Compliance and Ethics
    Health Care Compliance Association
    Office: 952.567.6219 | Mobile: 612.207.3172
    6462 City West Parkway | Eden Prairie, MN 55344
    ------------------------------

    Default Blank


  • 3.  RE: Policy on Policy

    Posted 06-30-2022 12:53 PM
    Thank you Steve! This is going to be helpful. If anyone could also share what their process is for handling policies that are not reviewed within the organization's required timeframe, that would be helpful too. For example, our organization requires yearly review/revision by the policy author, then the policy committee must review and approve. What do you do with a policy if the author doesn't provide a timely review? Do you retire the policy and then reinstate it once the author provides the required review?

    Thank you!

    ------------------------------
    Chris Ambrose, MBA, CHC, CHPC
    Compliance Officer
    Service Access and Management, Inc.
    Lewisburg, PA
    ------------------------------

    Default Blank


  • 4.  RE: Policy on Policy

    Posted 07-01-2022 09:38 AM

     

    Reminders are sent out well in advance for responsible parties to approve their policies (our Risk Management department has ellucid Policy Manager).   Our two critical access hospitals review annually, and for our acute care hospital, it's every two years.  However, there are managers/directors that do not get to each policy before the due date.  The Risk Management staff do their best to hold everyone accountable, but currently there really aren't any consequences for those who are late.  Personally, I think they should be reported to their VP and their lack of timely completion should be addressed.

     

    Cinda

     

    ******************************************* This message and any attachments to it may be confidential and are intended solely for the use of the individual to whom it is addressed. If you are not the named addressee you should not disseminate, distribute or copy this e-mail. Please notify the sender immediately by e-mail if you have received this e-mail by mistake and delete this e-mail from your system.



    Default Blank


  • 5.  RE: Policy on Policy

    Posted 07-05-2022 08:10 AM
    Thank you Cinda,

    I share a similar experience as you describe; reminders well in advance and most of the policy authors complete their reviews timely. I like your suggestion to communicate to the author's VP/Director etc. I've been hesitant to do that in order to preserve the relationship with the author, but, if doing so is required by policy, it hopefully lessens the chances of anything being taken personal.

    ------------------------------
    Chris Ambrose, MBA, CHC, CHPC
    Compliance Officer
    Service Access and Management, Inc.
    Lewisburg, PA
    ------------------------------

    Default Blank


  • 6.  RE: Policy on Policy

    Posted 07-06-2022 05:54 AM

    I shared a similar experience when I worked for a healthcare system. Policies were reviewed every 3 years for joint commission purposes, 2 for critical access. While the policy management system did a good job of sending out automatic reminders as to upcoming deadlines, they were ignored by many. It created a lot of problems until the joint commission window approached when it was a sudden race to chase people down to do their policy updates. A policy is great but definitely educate on the "why" behind it because unless that's clearly understood the cycle is likely to repeat in my opinion because people will just continue to rank this low on their list of priorities. 



    ------------------------------
    Brenda Manning JD, CHC, CHPC
    Privacy Counsel
    Maximus, Inc.

    The views expressed herein are my own and do not represent those of my employer. They are not meant to constitute legal advice or create an attorney-client relationship.
    ------------------------------

    Default Blank


  • 7.  RE: Policy on Policy

    Posted 07-06-2022 07:30 AM
    Great point Brenda, thank you!

    ------------------------------
    Chris Ambrose, MBA, CHC, CHPC
    Compliance Officer
    Service Access and Management, Inc.
    Lewisburg, PA
    ------------------------------

    Default Blank