Skills Competency Educationfor

New PI Directors and Coordinators

Session Six March 28, 2006

Sponsored by: The MT Rural Healthcare PI Network

Co-Sponsored by: The Mountain Pacific Quality Health Foundation

Session Six Learning Goals

To understand the critical role that policies and procedures perform in organization communication;

To understand the role of policies and procedures in managing organization medical-legal risk;

To understand the difference between a policy and a procedure;

To share guidelines for policy and procedure development.

MHREFNOVEMBER 18-19, 2003

DRAFTING POLICIES AND PROCEDURES

Michelle A. Williams, J.D. Gary McClanahan, J.D.Alston & Bird LLP Alston & Bird LLP404-881-7594 404/881-7632mawilliams@alston.com gmcclanahan@alston.com

I. WHAT ARE POLICIES AND PROCEDURES?

WHAT ARE POLICIES AND PROCEDURES?

• Policies are a reflection of the Hospital’s mission and operations

• Procedures are a description of the steps necessary to accomplish a policy

• Policies and Procedures have intended uses and get used in unintended ways

WHAT ARE POLICIES AND PROCEDURES?

• Policy and Procedure Manual is first thing surveyors and investigators request regardless of what Agency they represent

• DPHHS for Hospital Licensure

• CMS for EMTALA

• OIG for Billing

INTENDED USES

• Manuals Are Used To Teach To Evidence Compliance with Law To Document / Defend

INTENDED USES

• To Teach– Operationalize Communication

– Minimize “Hand Me Down” Education

• Required By Law– CAH Conditions of Participation

– State Hospital Licensure Law

– Federal CLIA Law

INTENDED USES

• Contractually Required

Hospital-Based Physician Agreements

Transfer Agreements

Corporate Integrity Agreements

INTENDED USES

• “Voluntary” Requirements

Accreditation

OIG Hospital Compliance Guidance

OIG HOSPITAL COMPLIANCE GUIDANCE REQUIREMENTS

       Risk Identification. The first element of a Compliance Plan is the development and distribution of written policies and procedures that identify specific areas of risk to the hospital.

        Standards of Conduct. Hospitals should develop standards of conduct that:

include a clear commitment to compliance by the hospital’s senior management.

articulate the hospital’s commitment to comply with all Federal and State standards, with an emphasis on preventing fraud and abuse.  

should be distributed to, and comprehensible by, all employees (e.g., translated into other languages and written at appropriate reading levels).

OIG HOSPITAL COMPLIANCE GUIDANCE

       Risk Areas. The OIG Guidance focuses on specific areas of potential fraud and provides specific examples of policies that should be implemented to ensure compliance in these areas.

       Claims Development and Submission Processes and Code Gaming (upcoding, DRG creep). There should be policies that create a mechanism for the billing or reimbursement staff to communicate effectively and accurately with the clinical staff.

       Ensuring That Claims Are Submitted Only for services that are medically necessary and that were ordered by a physician or other appropriately licensed individual.

OIG HOSPITAL COMPLIANCE GUIDANCE

       Anti-Kickback and Self-Referral Concerns. The hospital should have policies and procedures in place with respect to compliance with Federal and State anti-kickback statutes, as well as the Stark physician self-referral law.

       Accurate and Timely Reporting of Bad Debts and Credit Balances to Medicare and other Federal health care programs.

       Records System. There should be a records system which should establish policies and procedures regarding the creation, distribution, retention, storage, retrieval and destruction of documents.

UNINTENDED USES

• Discoverable Surveys

• Part of Plan of Correction

Lawsuit Defense• Define Standard of Care

EXAMPLES OF POLICY MANUALS

• Administrative • Departmental Level• Credentialing ■ Laboratory• Human Resources ■ Radiology• Purchasing ■ Medical Records• Nursing • Privacy • Infection Control • Compliance • Disaster

POLICY MANUAL TYPE DOCUMENTS

• Hospital Bylaws

• Medical Staff Bylaws

• Medical Staff Rules and Regulations

• Employee Handbook

• Compliance Plan

• Quality Improvement Plan

• Code of Conduct

WHAT IS THE DIFFERENCE?

• Plans / Bylaws / Handbooks Subject matter framework Source of policies and procedures

• Policies and Procedures Operationalize Plans and Bylaws

• Who

• How

• Where

• When

INVENTORY

Manuals Bylaws/Plans/Other

II. ELEMENTS OF A POLICY AND PROCEDURE

POLICY AND PROCEDURE Review and Management

• Identify Criteria for When Needed• Review Existing Manuals / Bylaws / Plans / Handbooks

Related Policies Pre-existing Policies Which are Similar

• Draft / Proof / Consensus / Trial Read by Users• Approval of Committee / Administrator / Board• Publication To Proper User Group• Inservice / Test• Revisions

ELEMENTS OF A POLICY AND PROCEDURE

• What is a “Purpose”? Goal Objective Aim What do you want to achieve?

• What is a “Policy”? Links the Purpose and Procedure Describes How the Purpose will be Achieved

ELEMENTS OF A POLICY AND PROCEDURE

• What is a “Procedure”? The Who, the What, the When, the Where Applies the Policy Series of Steps

• How is Policy Different from a Procedure?

III. PRACTICE POINTERS

DRAFTING DON’Ts

• “Must”/“Shall”

• Assume the “Subject” “Dr. Called”

• Forms Without Policies

• Use of Negative Statements “Never” “Do Not”

• Use of Abbreviations

• Time Designations Immediately / ASAP

• Use of Jargon

DRAFTING DO’s

• Use of the Word “May”

• Use of the Word “Should”

• Read Aloud

• Test on Users Before Adoption

USE OF DEFINED TERMS

• Definition

• Consistent Use of Defined Term

• Capitalize

“POLICIES AND PROCEDURES”POLICY

• How To Draft A Policy and Procedures

• How To Obtain Approvals

• How To Revise A Policy and Procedures

• How To Retain Old Policies and Procedures

• How To Document New Employee Training and Annual Training of Policies and Procedures

• How To Inservice New/Revised Policies and Procedures

PITFALLS

• Survey citations for “Not Following Hospital Policies on ________”

• Passive Voice Rather Than Active Voice

• “Prescriptive” Policies

• Drafts not marked “Draft”; Undated Drafts

• Use of terms “standards” “guidelines” “policy” “protocol” interchangeably or without definition

PITFALLS

• No Review and Revision Conducted

• Solitary Drafting and Annual Review versus “Qualified Group of Professionals”

• No Tracking and Retention of Policy Revisions

• Not Following Policy and Procedure

• No Monitoring to Confirm Policy and Procedure Being Followed or If Not, Why Not

READING COMPREHENSION

• Grade Level: 4th and 8th Grade Reading Level

SMOG - 10 consecutive sentences at the beginning of the document, 10 consecutive sentences in the middle, and 10 consecutive at the end. Count the number of multi-syllable words (3 or more) including repetitions. Then take the nearest perfect square root of that number and add 3. That gives you the reading level. Hyphenated words count as one; numbers and abbreviations: pronounce them aloud and count the number of syllables

Word Count Software: Voice and Grade Level

QUESTIONS