In healthcare organizations, one of the main objectives of leadership strategic planning is to assess the ability to develop new clinical programs to achieve continuous operational growth. One of the most important but often neglected operational strategies to achieve new clinical program goals is the implementation and validation of key regulatory documents.ย Policies, standard operating procedures, and associated reference forms are essential documents to validate the program’s success. During the survey, these should already be vetted, approved, and readily available for review by the surveyor during the accreditation phase of any new program implementation.
The mandatory documentation control procedures are clearly defined by the regulatory agencies such as CMS who provide the directives for patient safety, standard operating procedures, and clinical services.ย The association between new program implementation and document control is critical because documents validate that clinical services are provided and ensure the organizationโs practice is in alignment with their policies, procedures, protocols, and reference forms.ย In the State Operations Manual Appendix A-Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, there is language throughout discussing the need for review of policies, procedures, and contracted services.ย The documents are to be validated with current practice during a survey to assure the organization is equipped to perform appropriately.
There are also regulatory directives regarding what should be represented on the policy template header, especially if you are a multi-system organization. ย It is required to specifically assign which hospitals are to be named on the policy template by the governing body.ย Hospitals are also required to have system governing body policies with the provider assignment in the template.ย If hospitals are run separately and not a multi-campus structure, each facility should maintain their own documents and should not be operationally integrated.ย In other words, the template has only the name of the provider assignment and the governing body for that specific organization who is responsible for the approval and upkeep of the documents.
If you struggle to align your operational strategy with the document control regulatory requirements, I have a solution!ย My resource guide, Guidance for Developing an Effective & Compliant Document Control Practice in Healthcare Organizations is available to you as a roadmap surrounding the regulatory requirements for policies, procedures, and reference forms.
In my guide, you will also have access to a host of templates such as a Document Control Plan template, a sample agenda for a Document Control Committee, and insight on how the regulatory agencies view document control, detailing the requirements healthcare organizations are required to follow.
And, as always, I would love to help you through your journey to achieve regulatory compliance or assist in detangling your current document control process!ย
#DocumentControl#Policy&Procedure#StandardOperatingProcedures
