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Policy Management Essentials: An Interview with IntraVires - Part 2

We continue part 2 of our interview series with Intravires Health Compliance Consultants. During this part of the interview, we shifted gears towards the policy review process, continuous improvement, and Bill Belichick.

Enjoy part 2 of our interview series!


Interview By: J.P. Cervo

Interviewees: Shelley Koltnow & Dan Fisher

Etactics: 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 policy teams 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 guiding policy by the standards of formatting, language, and how things are expressed.

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 policy process will be less reliable. They should also review the policy with the sponsor and authors to make sure the policy is legally sufficient and that it meets the terms and requirements for compliance.

KPIs for the policy committee:

  1. The policy committee should be required to suggest any technical revisions that pertain to the accuracy or clearity of the policy.  
  2. The policy team should complete an agenda each meeting. This will ensure that the team spends the appropriate amount of time on each policy they plan on reviewing.

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

Dan: This is another call to action for the policy coordinator. After the policy team approves a policy, they suggest new revisions. Any revisions they have received get passed on to the policy coordinator who has the duty to look at the policy before it enters the manual and is distributed to employees. The policy coordinator checks to see if the policy is formatted properly and has been proofread, dated, and, if the version of the policy the team approved, if it will be going into the manual.

Etactics: Let’s assume for a moment that I am sponsor and part of the policy 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 sponsors main duties is that they follow the process that is present in the guiding policy. The guiding policy 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 policy 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 policy coordinator should receive read receipts, attestations, or someway of tracking when the policy is sent out and how many people open it.

  2. Set some turnaround time where people can ask questions about the policy or if they have concerns. This way someone on the team, a sponsor, or a coordinator can answer the question in a certain amount of time so the policy doesn’t sit for too long.

Etactics: 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 the policy management process, 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 policy is issued, it becomes available and easy to access by the organization. The communication process flows according to what level the policy is issued at, whether it’s an organization-wide policy, department-wide policy, or process SPO.

In any event, the authors and management of the area impacted by the policy are responsible for conducting education and training for those who need it. Remember that the policy 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 employees governed by the policy 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 policy manual and where they can find the most recent version of the policy.

Etactics: 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 the policy management process?

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 when employees whether they’re doing a job that's impacted by a policy, they are drafting a policy, or they are developing a new policy are following the process.

This policy 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 policy 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 a policy gets published properly, its 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.

Etactics: 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 that policy management process that they can truly rely on?

Shelley: I think one of the old addedages 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 policy process is reliable and show deficiencies that come from failures in this area. Another way of to make sure your process is reliable is ensuring that any external audits and reviews can be easily accessed in the policy in the case of liability. For example, stating that the proper policy at the proper time was followed can be very important in defending an organization against a claim or concern.

Etactics: Let’s say an organization has established that repeatable and reliable policy management process. 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 a 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 have 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. 

Etactics: We’ve covered quite a bit over the past few interviews and there appear to be many few moving parts as well as contributors when it comes to the policy process. How can organizations, small or large, begin to streamline this process and make life a little bit easier when establishing a sound policy process?

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 afterwards with someone who has the time to make sure that all important 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 policy 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 policymaking 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 policy management system.

Etactics: 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 a successful policy management process. What are the benefits an organization can enjoy when combining these two available resources?

Shelley: If an organization is new to establishing policy 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 policy process and increase its effectiveness.