It is often a gargantuan task to manage policies and procedures in hospitals. It is not unusual for even smaller hospitals and urgent care facilities to have upwards of 1,000 policies in effect, with the number only going up according to the size of the hospital. After all, the number of departments and the number of individuals responsible for reviewing and approving final policy documents can be very large, which makes the number of policies and procedures very high. That’s what makes the task of organizing all of this potentially intimidating.

Knowing this, it’s no wonder hospital administrators tend to look for a policy management system with the capability of doing everything from providing easy access to current policy documents to all staff, to managing the review process. However, one critical feature that is too often overlooked is one of the most important, and that is a revision tracking and archival engine.

Such a feature is critical, even though it doesn’t come into use on a daily basis. Sometimes, it is important to know which hospital policy was in place on a particular date, who approved it and who had access to it. Sometimes, it can be needed for an internal audit, but it can also be useful when policies are being reviewed by accreditation bodies or regulatory agencies. Given the strict regulations governing medical care, proper policy record keeping should be considered as important as patient record keeping. Also, if the hospital has been hit with a malpractice lawsuit, it can often be critical to know which policies and procedures were in place at the time of the claim and who knew about them. The consequences of not being able to find this information can cost a hospital dearly.

That is one reason those deeply involved with policy and procedure management can usually tell you which information must always be retained with each version or revision of a hospital policy. Any policy management system should allow you to provide the following on demand, for any purpose:

  • A read-only copy of a published document exactly as it was published, along with specific dates when that document was in effect and accessible to staff, as well as dates when every version of was approved, published, revised and/or archived;
  • Read-only copies of supporting documents used during the approval process, such as a redline version of the policy;
  • The names of the authors of the document, as well as the names of all approvers, along with specific dates when those individuals reviewed and approved the document.
  • Records indicating when each staff member reviewed and acknowledged reading required policies using a digital or physically signed document, depending on whether you are using a manual or an automated policy management system.

There is one true thing in any process; it is almost always far easier to build smaller and more focused record keeping steps into your current workflow than to track down this information later, when it may come up missing. By being proactive in putting these measures in place, you can prevent a lot of uncomfortable scrutiny for your hospital later on.