Management P&P Checks and Balances: A Foundation for Success

MRA team members working at a healthcare organization conference room to establish management p&p

Written policies and procedures (P&P) are an essential part of any business, operation, department, and job function. Promoting consistency and continuity are some of the benefits to having P&P in place and utilized. It’s a management duty and obligation to put in place policies and procedures and monitor their use and when changes are needed.

Policies and procedures sometimes bring about a negative feeling in employee’s and in Management. But the fact is having P&P in place is a fundamental way to ensure that day-to-day operations will be successful and compliant, which is a good thing!

Formal, written policies and procedures improve overall organizational performance by keeping everyone “on the same page” when it comes to expectations and job functions. Written policies and procedures also help with coherent decision-making and promote standard processes. In addition, P&Ps can help improve work production and/or identify when there are issues that impact production and/or efficiency. The written P&Ps help to provide the presumption and outcome of the job and duties for all employees or an individual department of employees. The benefits can be far reaching in having written policies and procedures.

From a healthcare Compliance perspective, the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) has developed some excellent guidance to help hospitals and healthcare organizations. Back in 1998, the first OIG release came out and then in 2005, an update. Both should be reviewed carefully. The 7 elements are very practical and not only organizations should develop these but even at a departmental level.

  • Designation of a compliance officer and compliance committee
  • Development of compliance policies and procedures, including standards of conduct
  • Developing open lines of communication
  • Appropriate training and education
  • Internal monitoring and auditing
  • Response to detected deficiencies
  • Enforcement of disciplinary standards

The above list of P&P can help establish a Coding Compliance Program, or even a CDI program as a framework and as a guide.

The “policy” is the portion that provides specific guidance, provides rationale or reason for the policy and the scope of the policy. While the “procedure” portion will outline the detailed function(s) and the steps to perform the function(s), the action to be taken and tasks to complete or avoid.

P&Ps come in all shapes and sizes, some are short, and some are long; some include pictures, and some do not. Some P&P will be basic to the healthcare organization (i.e., timecard completion, harassment, sick leave, vacation, dress code, etc.) and others will be specific to a department and a job function (i.e., ICD-10-CM Coding, CDI Query retention). The elements to include in the P&P may be similar to the following:

  • Heading
  • Title
  • Number
  • Date
  • Background
  • Definitions
  • Policy (reason and rationale)
  • Procedure
  • Consequences (Failure to comply)
  • Date approved
  • Approved by:
  • Next Review Date/Year

In an effort to improve and understand one’s departmental operations, here are some key questions to ask your Practice, Department, or Program about your policies and procedures (this is not an all-inclusive list):

  • Are policies and procedures clearly written relevant to day-to-day responsibilities?
    • Do they cover all essential functions and aspects of the job?
  • Are the P&Ps readily available to those who need them, and re-evaluated on a regular basis?
    • We typically see P&P reviewed annually or biannually. However, if there is a system change or a regulatory change that impacts the job function, then reviewing and updating the policy is needed sooner.
  • Does the internal compliance staff monitor your internal policies and procedures?
  • Has the standards of conduct (Code of Conduct) been developed and been distributed to all staff?
    • A Code of Conduct serves as a guide for professional behavior for those who hold specific credentials or certification.
    • For your Clinical Coding and/or CDI staff you’ll want to obtain and read over the professional association (AHIMA and/or ACDIS) standards as well. There may be information to incorporate into your internal policy.
  • Has the hospital, organization, or department developed a risk assessment tool, which is re-evaluated on a regular basis, to assess and identify weaknesses and risks in your job functions or the operations?
  • Does your P&P include all components of the job task or function?
    • This policy should clearly outline the expectations of each individual involved in the task, function and/or process, including the expected time frames in which completion should occur.
  • How is the P&P communicated and disseminated to employees?

Having written policies and procedures does not preclude Management from overseeing that the P&Ps are adhered to. Ensuring that employees understand and follow the P&Ps is another aspect to Managements responsibilities. Conducting an assessment of adherence to the P&Ps is a great activity for Management which helps promote checks and balances. When a new employee is hired, that is the first time (opportunity) your employee should be exposed to the P&Ps. It is an important practice for managers to incorporate into their annual planning and routine calendar the review of P&Ps. I’ve seen a process for this to include assigning 2-3 P&Ps for a group of 2-3 employees to review and provide feedback on. This really helps develop employee buy-in to the importance of the P&P. It also can provide a different perspective of the job function or duty so positive change can be made. Management needs to have a process in place to conduct the “checks and balances” of the policies and procedures as this can be as important as just having the P&P itself.

It’s spring, the time is now to pull out your P&P and dust them off, review them. Also, it’s time to determine if there are any new P&Ps needed. Having written P&Ps builds upon a culture of transparency, efficiency, and compliance. They also provide the guardrails for one’s duties and functions. The results of having P&Ps in place can help to bring about a very successful and efficient job function, department, and aide in helping your employees succeed as well as your organization as a whole. The P&P provides guidance and actions for Management and employees to take, which generates the needed checks and balances.

References:  AHIMA Standards of Ethical Coding; AHIMA Code of Ethics; 10 Examples of Policies and Procedures in the Workplace

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