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PolicyPLUS Webinar - Effective Policy Writing and Management

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Why documentation is so important: Tips that could keep you out of trouble later. …

Why documentation is so important: Tips that could keep you out of trouble later.
Who should write policies (qualifications of good policy writers).
What are the differences between policies and procedures.
When to use handbooks, manuals, flowcharts vs. policies.
How to achieve consistency using standardized policy attributes and format.
How to organize policies (classifying and numbering).
When policies should be reviewed and/or revised.

Our speaker Candace J. Chitty, BSN, MBA, CPHQ, PCMH-CCE is a NCQA PCMH reviewer and an expert in the NCQA patient centered medical home model and recognition process

Published in: Healthcare, Business, Education

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  • 1. 1 Candace J. Chitty RN, MBA, CPHQ, PCMH-CCE
  • 2. Your Key to Online Compliance Management 2  Why documentation is so important: Tips that could keep you out of trouble later.  Who should write policies (qualifications of good policy writers).  What are the differences between policies and procedures.  When to use handbooks, manuals, flowcharts vs. policies.  How to achieve consistency using standardized policy attributes and format.  How to organize policies (classifying and numbering).  When policies should be reviewed and/or revised.
  • 3. Your Key to Online Compliance Management 3  Public Companies  Answer is easy...to satisfy various laws including HIPAA, HRSA, IRS, and other federal, state, and local laws, and accrediting entities (TJC, NCQA, etc)  Private Companies  Answer is not as easy...follow similar laws as public companies  Not-for-Profit Companies  Answer is easy...to satisfy various laws including HIPAA, HRSA, IRS, and other federal, state, and local laws, accrediting entities (TJC, NCQA, etc), and granting agencies.  Additionally, the new IRS Form 990 asks whether nonprofits have certain policies relating to governance. You don’t want to answer “no”
  • 4. Your Key to Online Compliance Management 4  Help make instructions and guidelines definite and help in the interpretation of policies and procedures  Provide quick settlement of misunderstandings  Help reduce the range of individual decisions and discourage management by exception  Cover recurring situations such that managers can begin to make decisions that will be consistent every time  Set boundaries for jobs so that each employee knows in advance what response he or she will get from others when taking actions, making decisions, and giving responses  Provide protection in the event of an audit or lawsuit
  • 5. Your Key to Online Compliance Management 5 Dissection of Key Words  WRITING POLICIES  EFFECTIVE WRITING  POLICIES and PROCEDURES
  • 6. Your Key to Online Compliance Management 6  What “Writing” IS?  Writing policies and procedures is more than typing words on a page; it involves research, writing a draft, reviews, approvals, publi shing, distributing, communica tions, training, maintenance, i mprovements, and revisions  Writing refers to the writer.  A writer is someone who understands how to gather the information, document a process, present the words in a logical fashion, and publish and train the audience to ensure the content is understood  Also, writing means to write consistently using a consistent writing format and writing style  What “Writing” ISN’T?  Writing content in a vacuum without involving the users and customers in the writing and reviewing processes  Buying canned content, attaching a logo, and calling it your own without sanitizing it to assure it aligns with our environment, culture, and resources  Expecting non-writers to write high-quality policies and procedures that people will understand and follow (a writer of business letters does not make a good policies and procedures writer)
  • 7. Your Key to Online Compliance Management 7  Good Choices  Someone with writing and editing skills who has the time and mobility to interview users and customers  Someone who has worked on process improvement projects  Someone with excellent organizational skills and a passion to write documents that can be understood by the targeted audience  Analysts, Subject Matter Experts, Leads, Supervisors, and some Managers  Not So Good Choices  Individuals who write business letters and correspondence but have never (or infrequently) written policies or procedures  Individuals who have the knowledge but don’t have the time  Individuals that take content from others and format it in their own style but don’t interview users to ensure the content is correct
  • 8. Your Key to Online Compliance Management 8  Identify policy/procedure topics  Conduct research  Write the first draft and making sure it is reviewed and revised  Obtain approvals, publish, and distribute documents  Issue communications and conduct training  Analyze documents for improvements and make revisions  And the cycle continues...from writing to revising to writing to revising...
  • 9. Your Key to Online Compliance Management 9  Effective Writing?  End result: Users can understand and apply the policy/procedure content to their work processes  Users have clear job responsibilities and know what’s expected of them, without guessing  Users can make better decisions when they know that the policy/procedure content will not change from one day to the next  Policies and procedures are consistent, accurate, and reliable from one document to the next  Not Effective?  Users ignore policies and procedures for a variety of reasons including:  Author is not a credible source  Poor or sloppy writing  Grammatical and spelling mistakes  Complex or wordy content  Unclear purpose or title  Approver of policy/procedure is not known to them or doesn’t have the right authority  Communications and training efforts are lacking or weak  Documents conflict with one another  Writing format is different from one document to the next  Policies/procedures change every other week
  • 10. Your Key to Online Compliance Management 10  Policies:  Describe the “What” the “Who” and the “Why”  Are a predetermined course of action established as a guide toward accepted business strategies and objectives  In a nutshell, “policies are guidelines dictated by executives and/or extracted from regulations”  NOTE: Other policy types could include public policies or institutional policies (not covered here)  Procedures:  Describe the “How” and are generally methods by which policies are accomplished.  Are a combination of one or more business processes  Identify the people, places, processes, f orms, and actions necessary to carry out one or more policies or to support or influence other procedures  NOTE: Procedures that address a single process such as how to complete a form or cash a check are often referred to as “Desktop Instructions” or “Work Instructions”
  • 11. Your Key to Online Compliance Management 11  AGREE on the importance of a writing format and agree on which writing format to use in which situation  AGREE on the use of a single writing format for policies and procedures or two writing formats for policy and procedure documents; and one desktop instruction format  AGREE on communications media to be deployed  AGREE on training methods to be utilized and repeated  AGREE to write a “Procedure on Procedures” to capture the essentials of writing policies and procedures
  • 12. Your Key to Online Compliance Management 12 1. What’s the justification? 2. Who authorizes? 3. Who manages function? 4. Who writes policies and procedures? 5. Do you deploy printed and/or online manuals? 6. Do you use 1 writing format, 2 writing formats; and desktop instruction formats 7. What’s your document numbering system? 8. Where does content come from? 9. What’s the layout of your writing format? 10. Are forms designed to align with policy and procedure content? 11. Who reviews drafts? 12. Who approves drafts? 13. Who distributes and publishes documents? 14. Who communicates? 15. Who trains? 16. Who audits? 17. Who monitors to ensure current regulations are taken into consideration? 18. Who recommends improvements?
  • 13. Your Key to Online Compliance Management 13 1. Management shows commitment to policies and procedures by authorizing the policy/procedure function 2. Person/team is assigned to write/manage policies and procedures from research to publishing to revisions 3. Topics are identified and researched 4. Drafts are written in a standard writing format 5. Drafts are reviewed by users and management 6. Drafts are approved (finalized) and published 7. Published documents are communicated and trained 8. Published documents are revisited to study possible improvements and cost savings 9. Published documents are subjected to a revision process that starts at #3 and the whole “topic-to- revision-process” becomes a continuous cycle
  • 14. Your Key to Online Compliance Management 14  Heart of a policies and procedures system  A writing format is a way to:  Present your content in a logical and easy-to-read sequence that makes sense to the targeted audience.  Present enough information about your content that helps the audience understand the importance of your policy or procedure topic.  Ensure consistency from document to document for both the policy and procedure documents.  A writing format contains a specific number of section headings and never changes after the writing format is approved for use
  • 15. Your Key to Online Compliance Management 15  Header – Logo, title, number, dates, approvals, revisions  1.0 Policy Statement  2.0 Responsibility  3.0 Definitions  4.0 Implementation (Procedures)  5.0 Documentation/Monitoring  6.0 References  7.0 Related Policies and Procedures  Optional documentation (appendices can be used as a way to include flow charts, diagrams, and other material)  Adding Section Headings  Possible additions include “Background,” “References,” “Document Approvals,” or “Disciplinary Actions”. If you add more headings, integrate them into the writing format and stick with that number of section headings  Never deviate for any reason: Consistency is King
  • 16. Your Key to Online Compliance Management 16
  • 17. Your Key to Online Compliance Management 17  Selections:  One (1) Writing Format that combines policy and procedure elements  Two (2) Distinct Writing Formats:  One (1) for a Policy Document  One (1) for a Procedure Document to cover two or more business processes
  • 18. Your Key to Online Compliance Management 18  Combines policy and procedure elements into a single writing format  WHY? Reduces redundancies, duplication, and inconsistencies when two documents cover the same, or similar, subject  Eases reading by the targeted audience by:  Providing a logical sequence of section headings starting with “Purpose”...and ending with “Revision History”  Not asking the reader to search out two documents that cover the same, or similar, subject(s)  Eliminating redundancy of two documents published on similar subjects
  • 19. Your Key to Online Compliance Management 19  Writing Format for single processes such as:  How to fill out a “Travel Request” form  How to request “Petty Cash”  WRITING FORMAT Section Headings 1.0 Purpose 2.0 Procedures (Step-by-Step Actions) 3.0 Change History 4.0 Document Approvals
  • 20. Your Key to Online Compliance Management 20
  • 21. Your Key to Online Compliance Management 21  Logo  Title  P/P Number  Department/Operational Area  Effective Date  Review, Revision, and Approval Date  Approvals  Page Numbers  Scope
  • 22. Your Key to Online Compliance Management 22
  • 23. Your Key to Online Compliance Management 23  Describes objectives, strategies, goals, culture, vision, mission , and other guiding principles for the topic stated in “TITLE” and “PURPOSE”  Can be a single paragraph, several sentences, and sometimes several pages  Opening sentence might say: “The policy of XYZ company is to: (Follow with statements or indented sentences)”  Be careful:  Don’t omit the “Policy” section heading when you don’t think there are any policy statements surrounding procedures (there is always a policy that guides a procedure, always)  Writing policy statements that don’t support the main focus of the “Purpose” section heading or the “Title” of the document  Using specific procedural statements instead of general policy statements
  • 24. Your Key to Online Compliance Management 24
  • 25. Your Key to Online Compliance Management 25  Summary of roles and responsibilities of the individuals or groups that perform actions in a policy or procedure  The “Responsibilities” section often parallels the flow of the “Procedures” section, where applicable  The responsibility section typically has at least two sentences:  “The [Title of Highest Approver] shall ensure compliance to this policy (or procedure)”  “Employees are required to…”  Be Careful:  There must be a “compliance” statement in every policy or procedure document  Don’t write procedural statements in this section; rather keep to the responsibilities of the roles stated  Don’t write actual names of persons; instead state only their roles or functions
  • 26. Your Key to Online Compliance Management 26
  • 27. Your Key to Online Compliance Management 27  Defines objects or terms like acronyms, abbreviations, forms, reports, flow charts, models, words infrequently used, or technical jargon  Don’t assume your audience has the same vocabulary as you  Be Careful:  Never omit a section heading  Not to leave this section blank: All policies and procedures have definitions of some sort  Failing to define content in this section that is later placed in the appendices as an exhibit or reference pointer
  • 28. Your Key to Online Compliance Management 28
  • 29. Your Key to Online Compliance Management 29  The Implementation section heading describes the rules, regulations, activities, timing, place, and personnel necessary to carry out the intent of the procedure and/or support the essence of the policy statements contained within the Policy section heading  The Implementation section heading is required for procedure documents but is optional for policy documents  Be Careful:  Never omit this section even if there is no content for a policy document  Ensure that the procedural statements support the policy statements  Ensure that the procedural statements follow the work flow
  • 30. Your Key to Online Compliance Management 30
  • 31. Your Key to Online Compliance Management 31  Contains information related to documentation requirements  Describes any surveillance and or monitoring activities to ensure/track compliance  Be careful:  Assure that all monitoring requirements are included in quality assurance/quality improvement planning  Don’t omit this section. If there are no documentation or monitoring requirements indicate by entering “
  • 32. Your Key to Online Compliance Management 32
  • 33. Your Key to Online Compliance Management 33  Contains information related to references used in writing the policy content.  Example:
  • 34. Your Key to Online Compliance Management 34  Crosswalks all related policies, procedures, and perhaps additional documents  Assists in managing consistency across documents when needed revisions are needed. Writers should conduct a consistency review of all related documents listed in this section when revising to ensure consistency remains throughout.  Example:
  • 35. Your Key to Online Compliance Management 35  Optional documentation can be added to any policy or procedure document  One method is to define the documentation (like a flow chart or report) in the “Definitions” section and refer to an appendix where the document has been included  Another method is to hyperlink a reference for electronic policies and procedures (opens in its own window)  In the case of a form, define it in the “Definitions” section, and either add a hyperlink to the template or in the case of paper forms, give directions on where to find the form (like a supply cabinet) and show a sample image in an appendix  Be Careful:  Don’t include an appendix without a reference notation from somewhere in the document or from the “Definitions” section  Don’t include a reference in the “Definitions” section and then fail to include the actual reference document or source either as a hyperlink or as an appendix to the document
  • 36. Your Key to Online Compliance Management 36 Two Methods: 1. Quickest... but acceptance is difficult: Find or purchase a canned (generic content) policy or procedure you like from a website or book, don’t change a word, add your logo, and call it your own. Unless you adapt content to your culture and people, buy-in is highly unlikely 2. Best Method: Assign at least one writer and/or form a cross-functional team, do research, use canned content for reference purposes only, interview users, brainstorm ideas, write a draft document, get it reviewed and approved, publish it, and communicate and train
  • 37. Your Key to Online Compliance Management 37
  • 38. Your Key to Online Compliance Management 38 Now that the policy/procedure document has been written, reviewed, approved, published, and distributed, the NEXT STEPS are to:  Communicate and train  Work on improvements for the next revision  Update the document publish the revision  Communicate and train...and so on
  • 39. Your Key to Online Compliance Management 39  Communications are key to policy/procedure implementation because it’s a quick way to impart information about policy/procedure content  Communication Methods can include:  Distribution of physical or electronic documents  Letters, press releases, newsletters  Paycheck stub or inserts  Posters, bulletin boards, or brochures  Team meetings, town meetings, staff meetings  Email messages or broadcast emails  Intranet news items  The KEY is to provide communications in multiple ways to give the reader added ways to understand the material. Keep in mind that the “just once” communications method and plan is not acceptable and plans must be made to communicate regularly to ensure continued understanding on the behalf of the employee and to reduce the tendency to “resist change”
  • 40. Your Key to Online Compliance Management 40  Training is defined as to make prepared, to teach to be proficient, to undergo instruction, or to practice.  In business, training is the formal process used to develop in an employee the attitudes, knowledge, and skills an employee needs to make him or her capable of efficient performance (i.e., less time to carry out assignments).  Training methods include but are not limited to:  Lectures, workshops, or seminars  Department or staff meetings  On-the-Job Training  Multimedia training and/or computer-based-training  Mentoring and coaching  Other creative training methods  The KEY is to train and then to repeat training through on-the-job training and mentoring.
  • 41. Your Key to Online Compliance Management 41 We have learned:  Writing Effective Policies and Procedures is NOT as simple as borrowing content, adding a logo, and calling it your own  Policies and procedures writers don’t just write and edit but they are also responsible for researching, writing, reviewing, approving, publishing, communicating, training, improving, and revising.  Incorporating a consistent writing format will:  Help the reader understand content quicker  Ensure consistent and accurate policies and procedures from one document to the next.  Most importantly, we have learned that a writer’s job is not over when the document is published...INSTEAD the writer’s job is just beginning…with communications, training, reviews, audits, improveme nt activities, and revisions.
  • 42. Your Key to Online Compliance Management 42  Management commitment to write policies and procedures  Qualified writers---More than just an editor  Same writing format template used every time  Communications issued in multiple media  Training offered in a variety of formats  Walk the Talk from management  Mentoring and On-The-Job Training  Ensuring legal review of all relevant policies  Annual policy/procedure reviews  Adding policy and procedure understanding as a percentage on an employee’s evaluation plan
  • 43. Your Key to Online Compliance Management 43 1. Select a writing format and stick with it 2. Write a “Procedure on Procedures” and stick with your decisions as you write policies and procedures 3. Designate a policies and procedures writer and give this person the tools, time, and mobility he/she needs to be successful 4. Don’t expect to be able to take a canned financial policy or procedure, make a few changes, add a logo, and call it your own if you actually want people to read and apply the content 5. Put a policies and procedures writer in charge, follow my advice, and do it right the first time...so that readers might actually read the documents and apply the guidelines to their jobs 6. Be proactive, as you are doing today, by listening to me talk, and by attending conferences, and learning tested methods for writing effective policies and procedures
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  • 48. 49 Questions & Answers Thank you for participating in the continuing PolicyPLUS Webinar series. If you have any comments or additional questions please do not hesitate to contact us. CJChitty@Qfhc.com RChitty@Qfhc.com www.Qfhc.com www.Qfms.org

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