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Six tips to create effective policies

Credentialing Resource Center Connection, June 9, 2004

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Dear credentialing colleagues:

Over the past decade, hospital medical staffs and administrators have had to tackle an increasingly complicated range of responsibilities.

The evolution of U.S. healthcare law has, for instance, made medical staff management more complex, while credentialing and privileging requirements make the process of granting privileges more involved. Managed care continues to create new financial pressures and prompt practitioner turf battles. To make matters worse, evolving JCAHO standards mean all is rarely quiet on the accreditation front.

The answer to many of today's medical staff and credentialing dilemmas is relatively simple. Medical staff leaders and administrators need effective policies to guide and manage these new responsibilities fairly, consistently, and confidently. Consider the following approach:

- Begin by reviewing your hospital's existing policies to determine whether they are clear, comprehensive, and up-to-date.
- You can use sample policies from The Greeley Company or other hospitals as a model for writing new policies or revising existing ones. Tailor the policy to fit your organization's needs.
- Have your legal counsel carefully review all new policies.
- Once the new policies are final, review them thoroughly with hospital staff, and discuss their intent and your plans for enforcing them.

As you develop new policies or revise existing ones, keep the following tips in mind:

1. Carefully word policies and procedures to avoid ambiguity. Clear language will result in effective policies.
2. Sign and date all policies and procedures.
3. Review policies and procedures at appropriate intervals (every two years works well in most cases).
4. Highlight changes in policy throughout your hospital.
5. Enforce policies and procedures strictly but fairly, and focus on any that govern activities that pose a significant risk to patients, staff, or visitors.
6. Carefully document each step in the process -- from development to enforcement.

Applied effectively, good policies and procedures will help establish clear lines of authority and communication within your organization. They should help you tackle a range of medical staff management issues and avoid potentially serious problems.

That's it for today.

All the best,
Hugh Greeley
http://www.greeley.com/seminars/

(Editor's note: If you need sample policies to use as a model, check out the book "The Top 30 Medical Staff Policies and Procedures, Third Edition," co-authored by Hugh Greeley and published by HCPro, Inc. Click on this link http://www.hcmarketplace.com/Prod.cfm?id=2377 for more information.

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