Policy Management: An Interview with IntraVires

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If you've ever worked within the policy management space, you understand its complexity. There are many factors to evaluate including…

  • Establishing a guiding policy

  • Appointing the proper team and coordinator

  • Adopting a charter

  • Setting expectations and achievable goals. 

We sat down with the legal professionals from IntraVires Healthcare Compliance Consultants to give organizations a better idea on how to get their action plan off the ground and keep it running as steadily as possible.



J.P. Cervo

Regional Sales Manager



Shelley Koltnow

Principal Compliance Consultant

IntraVires Healthcare Compliance Consultants



Dan Fisher

Compliance Consultant

IntraVires Healthcare Compliance Consultants


J.P.: Shelley, the focus of today's interview is on best practices when it comes to policy management.

Would you start us off by defining what best practices are and how to identify them?

Shelley: To find out what your best practices are, folks can look at past experiences to better identify what their organization does well and then compare those to objective standards established by other organizations. From there, a benchmark can be set to guide how the process can be improved. Repeating this cycle allows an organization to move the needle toward better performance through continuous improvement.

Comparing your performance each time, possibly at the end of each meeting via a group discussion, can help you recognize and establish key performance indicators, or KPIs, as benchmarks for those processes that the organization seeks to improve.

When members own the process, so in this case the coordinator and the committee, they will be more likely to solicit feedback. They might send surveys from time to time, see if others feel the process is in line with the stated goals and objectives, and continually follow the processes as established or as agreed to enhance the reliability. The more reliable a process is the more likely it will be successful. The organization can review and revise parts of it that aren’t working as expected.

J.P.: Can you exlplain what a benchmark is in the policy management process?

How can you identifywhat those benchmarks are and use the moving forward.

Dan: A good note to make about benchmarks is that they’re temporary. They evolve. Whenever you establish your indicators for how your process should go or what best practices you find, those benchmarks can change over time as your policies change, your organization changes, or best practices change. So when you really set your standards and are aware, they are able to evolve and mature. Establishing a benchmark is a great way to help measure your reliability. That way you can physically see if you’re working towards the goals you’ve set to determine if you’re on track.

J.P.: During conversations we’ve had in the past, you’ve stressed the importance of creating a guiding policy to memorialize the management process.

How can an organization incorporate these elements so that it becomes both repeatable and functional?

Shelley: We’ve mentioned in the past about how important it is to have a policy that lays out all the steps of a reliable management process. But as a recap, a guiding policy has to contain those components. It…

  • Explains the steps in the management process
  • Creates a roadmap that process owners follow and then makes sure that tey are following
  • Helps the team establish a template for their manual and new guidelines to ensure consistency

J.P.: Another critical step in establishing policy management process is designating a coordinator.

How can you determine who the best candidate is to fill the position?

Shelley: It’s important for a coordinator to be able to manage the process. There are two errands that lead into that. First, they need to have the skillset, of course. Second, they need to have the bandwidth to able to do it. There has to be some consideration for the person’s ability to have the time to do this job well.

We also recommend that the organization has recognition for this position in a couple of different ways; the person’s job title, or compensation. The management should really endorse a whole process of recognizing the effort that is going to be made by the coordinator, especially because this person is going to be accountable to perform job instructions specific to that responsibility.

A couple of KPI's for the policy management coordinator...

  1. Are they successful in the first six months in meeting the job instructions that were initially created?
  2. Are they meeting the requirements or measurements for their job?

J.P.: You’ve mentioned how assembling a team to support the coordinator is important.

Can you reiterate the importance of having this team and who should be considered to fill these positions?

Dan: Team members have to be willing to participate and be invested in the policy management process and management needs to be copacetic.

A few factors to keep in mind are...

  • Members having the time to serve
  • A distraction from their daily jobs
  • Their willingness to serve

They don’t need to be high-level personnel, so executives or senior directors don’t necessarily need to be the one to serve on the policy management team. It can be processed owners, employees who are more knowledgeable about a certain smaller area of the company, or it can be the subject matter experts who are familiar with the process.

I think the most important factor to keep in mind is that the team members want to participate. Putting them on a team can be a good way to motivate them and building a team that works well together can quickly build momentum. The team’s membership should be representative of the whole organization to make sure that the team has a holistic view of the company and whenever policies come through, members can be subjected to matter experts in their respective area.

J.P.: The first duty of the policy team is to develop and adopt its charter which serves as the backbone when the team needs inspiration.

What parameters should be included in the charter so the team is authorized and able to fulfill it?

Shelley: The charter is really like the constitution for the committee so it’s important to put in issues that pertain to membership on the team; like how members are going to be appointed and re-appointed, defining terms of membership, who nominates members, and attendance requirements. For example, charters may say that members must attend at least three-quarters of the meetings, either in person or by phone.

It may also include whether or not the organization will allow a member to send a substitute or what steps to follow if a member needs to be replaced. For example, if a person leaves the committee because their roles or responsibilities within the organization change, how do you replace that person and what’s the process.

The charter should also address the meeting requirements such as how often, what time of day, and where the meeting will take place. You can add in other ways of holding these meetings like whether or not telephone meetings or Skype meetings will be acceptable if everyone is in a different location. Along with setting the requirements for the meetings, someone should be appointed to take minutes and have clear guidelines on how the minutes should be taken. Finally, it should explain how the charter will be amended if any provisions need to be added or removed if it changes during the process.

J.P.: How do you decide the roles and expectations for the different members of the policy management team?

Dan: A great way to make sure that people know what role they play in the team is to set expectations before the team meets and the process kicks off. Anyone could have the opportunity to become an author or co-author and possibly delegate their writing to a support staff member.

Though anyone can stop being an author, normally sponsors are senior directors or executives who are held accountable for their specific area of the organization along with reviewing policies that relate to their area of expertise and supporting the authors.

A couple of KPIs to consider with the policy management team...

  1. The policies should be submitted with an author and sponsor listed. This helps the organization see what roles everyone played in the drafting process.
  2. The policies should be submitted before they expire to show strong communication between the authors, the sponsors, and the team.

J.P.: Why is the review process so crucial to the success of an organization’s ability to manage its policies and what areas should always be addressed during the review process?

Shelley: As the policies go through the review process, it’s the team’s job to make sure all the elements of the guiding policy are present because these elements are the rules of the road for the organization. The team makes sure that policies are clear, accurate, and reflect the main one by its formatting and language standards.

They have to be accurate about how the process is followed for the members that will take their place in the committee because if the language is unclear or ambiguous, the team becomes less effective and the process will be less reliable. They should also review it with the sponsor and authors to make sure it’s legally sufficient and that it meets the terms and requirements for compliance.

KPIs for the policy management committee...

  1. They should be required to suggest any technical revisions that pertain to the accuracy or clarity.
  2. They should complete an agenda during each meeting. This will ensure that the team spends the appropriate amount of time on each.

J.P.: What would you consider to be the technicalities in policy management and how can you make sure they’re being followed?

Dan: This is another call to action for the coordinator. After the approval process, they suggest new revisions. Any revisions they have received get passed on to the coordinator who has the duty to look at it before it enters the manual and is distributed to employees.

The coordinator checks to see if it is formatted properly and has been proofread, dated, and, if this version is approved by the team, it will go into the manual.

J.P.: Let’s assume for a moment that I am sponsor and part of the management team, what is my role as a sponsor in the distribution process of a policy that was recently published by the organization?

Dan: One of the sponsor's main duties is that they follow the process that is present in the guiding policy. This guideline doesn't just apply to the team, it applies to all of the employees, all of the authors, sponsors and anyone involved in the policies themselves. A sponsor can communicate with the coordinator and the team to make sure what they submit gets necessary revisions, receive a notice that the team approved it and that they rely on that process. Since the sponsors oversee these areas and they are the senior leaders, they’re held accountable to make sure this process is working for them and their team.

It’s a good idea to make sure that their employees, authors, and anyone in the organization has some sort of line of communication to give feedback. Once a policy is published, the sponsors should be notified that someone might call them with a question, a concern about what’s written, or give feedback to an appropriate contact.

KPIs for the sponsor and coordinators...

  1. The coordinator should receive read receipts, attestations, or some way of tracking when the guideline is sent out and how many people open it.
  2. Set some turnaround time where people can ask questions or give concerns. This way someone on the team, a sponsor, or a coordinator can answer the question in a certain amount of time so it can keep things moving.

J.P.: We could host an entire series of interviews on the importance of effective communication and how a lack of communication hinders any organization or business unit.

When we talk about communication in policy management, what measures can be taken to promote continuous effective communication?

Shelley: One of the first methods is to have a robust distribution process so that when a new administrative action is issued, it becomes available and easy to access by the organization. The communication process flows according to their issued level, whether it’s an organization-wide, department-wide, or process SPO.

In any event, the authors and management of the area impacted by the guideline are responsible for conducting education and training for those who need it.

Remember that the committee is not responsible for the education, but rather to ensure that education has been conducted if it’s needed. Sponsors are held accountable for making sure when the education has been completed and documented so that any questions or concerns can be brought back to the author to ensure that they will be handled through a feedback loop or an amendment loop.

KPIs about communication...

  1. Track how many governed employees have actually attended the education and training sessions. This can be tracked with sign-in sheets and maintained in the department that is conducting the education.
  2. Communicate to employees how to access the most recent version of their manual.

J.P.: One of the most successful coaches of all time in the NFL and across all major professional sports is Bill Belichick. Throughout his coaching career, his motto has been “Do your job”.

I’ve always felt that ideology can be applied to any activity that is completed in a collaborative effort. So how is this specifically applied to policy management?

Shelley: I love the reference to a sports coach here because when everybody does their job, the process becomes very reliable. It will work every time whether employees are doing a job that's impacted by a policy, they’re drafting one, or they are developing new ones.

This process can be memorialized in a team’s meeting minutes. These notes are the reflection of what the group is doing each time they meet. Meeting minutes should be kept and detailed enough to support an understanding that they are doing their job.

The review dates, the meeting dates, and other key dates should be calendered and stress the importance of attendance in these meetings. It’s important for the members to be tracked, calendered and that there's an understanding that these are standing meetings that need to be attended.

The team also has to make sure that everything is published properly, they’re made readily available, and any questions or concerns get feedback to the author and sponsors so that they can be managed within the process. Finally, they have to make sure that they have an understanding of whether they could have done anything better because that’s the basis and foundation for continuous performance improvement.

J.P.: Everything that’s been covered up to this point leads to establishing both a repeatable and reliable process.

Why is it so important for an organization to have reliable policy management?

Shelley: I think one of the old adages that we follow is that variability is the source of errors. The more reliable and repeatable a process is the less likely something will go wrong. For an organization to demonstrate this is an objective measure to show how your whole organization takes this process seriously and puts time and effort into it.

So accreditation, surveys, and various audits and reviews will contain findings that your processes are reliable and show deficiencies that come from failures in this area.

Another way to make sure your process is reliable is ensuring that any external audits and reviews can be easily accessed in the case of liability.

For example, stating that the proper guideline at the proper time was followed can be very important in defending an organization against a claim or concern.

J.P.: Let’s say an organization has established policy management that is repeatable and reliable.

Why should they be concerned with trying to find areas for continuous improvement and what best practices can the organization implement to promote this kind of improvement?

Shelley: Just like the delivery of service to a customer or care to a patient, it’s important for management to keep its own processes in the high-reliability and high-quality realm. Continuous performance improvement is one way to do that and it makes sure that the most efficient and effective way of handling a process is followed. The PDCA process which is “Plan Do Check Act” is a way that we can perform self-assessments.

We can look back and see what we could’ve done better and discussed any suggestions that come from the process, possibly at the end of every meeting. We lay out what could have been done better, how we can do it better, we try it that way, and we check and make sure that it is better. We start the process over again and by doing this we continuously move our process towards a higher level of accuracy and reliability.

J.P.: We’ve covered quite a bit in this interview and there appear to be many moving parts as well as contributors when it comes to the policy management process.

How can organizations, small or large, begin to streamline this process and make life a little bit easier when establishing it?

Dan: I think the best two tips are to do research and use tools. One of the keys to making something reliable is continuous performance improvement and benchmarks. That best practice or benchmark changes as you do more research or as times change. There are tools that can help you do that and these include things like checklists that cover all your steps in the process, making sure that during meetings you’re going through everything required, and keeping minutes at meetings that can be reviewed with someone who has the time to make sure that all topics were covered.

You can also start using surveys and feedback from employees to make sure that they know how to find policies, how well your systems are working, what they think of them, and if are they easy to follow. Technology solutions, such as the one you provide at Etactics, can help you facilitate distribution or make things look more presentable.

You can use independent audits and reviews of your management system to make sure that someone can follow it and that it’s well controlled. Teams can do self-assessment to make sure that when they contribute to the drafting process they’re making a difference, the team and the coordinator are working well together, and sponsors really know what their areas are covering and how they're supposed to interact with the team.

Along with research, there are a variety of different forums, journals, webinars, and other educational resources that your company may subscribe to. Journals provide great research allowing you to see how other people or other companies are working on their management system.

J.P.: You’ve referenced how software is a great aid and resource to facilitate some of the vital components that fortify strong policy management. Consulting is also an invaluable resource to help develop success.

What are the benefits an organization can enjoy when combining these two available resources?

Shelley: If an organization is new to establishing administrative processes, planning to upgrade its processes to a higher level, or planning to automate processes it’s important that they cover a lot of ground because there’s a lot of different moving parts.

Putting together a good guiding policy is something that consultants can help them with as well as making sure that all the steps to the process are touched on by all the tools that are going to be used and possibly suggest some different tools.

A way that we like to offer our services is by helping install a good technology solution that covers processes and tools that help the process work well. In automating things like meeting dates, review dates, expiration dates, and due dates in a standardizing template, technology solutions can take a lot of the hard work out of a really strong process and increase its effectiveness.