Writing Compliance Policies and Procedures for Healthcare: An Expert Guide 

Few things can improve healthcare compliance more than writing new policies and procedures, especially given the rapid evolution of Artificial Intelligence (AI) and growing cybersecurity threats. Yet many leaders believe drafting new policies must be a painstaking process that requires months of effort and hits their budget hard. 

This article explores a different approach that enables leaders to refresh their policies more efficiently,  addressing gaps, improving employee comprehension, and strengthening the culture of compliance.  

Why Healthcare Compliance Policies and Procedures Matter  

Healthcare is one of the most heavily regulated industries, but the average employee cannot reasonably be expected to become an expert across all areas of compliance. Instead, they should be supplied with clear policies and procedures that govern their behavior, set and maintain standards, and help individuals understand what is required to protect both patients and the organization. 

The problem is that managing a large volume of policies creates a great deal of complexity for compliance teams, including: 

• Outdated Policies: Policy development and implementation often struggle to keep pace with evolving requirements, especially in areas like IT and cybersecurity that change fast and require deep expertise. 
• Storage Issues: Policies are often inconsistent, with a mixture of digital and hard copies existing within the same organization. 40 percent of healthcare compliance documents are stored in binders or spreadsheet software, both of which can invite mistakes and potential liability.  
• Adoption Rates: The biggest problem may not even be the lack of policies, but the difficulty in ensuring employees follow them. Many policies appear to be written to meet regulatory requirements, rather than actually help employees understand and meet those requirements. This leads to several issues that make policies less effective. 

Three Problems with Most Policies and Procedures  

After over 30 years of experience helping healthcare organizations develop and implement more robust compliance measures, our team has identified three persistent issues with policies and procedures: 

1. Lack of Clarity 

Policies and procedures are only worthwhile if employees can use them to direct decisions or behavior. However, many policies are written with a lack of clarity and specificity, making it harder for employees to understand and enact them.  

We have identified three common sources of this confusion: 

• Ambiguity: Many policies use vague or ambiguous language that could be interpreted differently by multiple stakeholders. For example, a policy states, “patient data may be shared with third parties where necessary.” The term ‘necessary’ could be ambiguous. It may refer to every doctor involved in the patient’s care, or only the primary caregiver. Similarly, the definition of third parties can vary – potentially including insurance companies, researchers, or even technology firms that manage medical records. 
• Terminology: Policies are written by compliance personnel who are highly familiar with specific regulatory jargon, technical terminology, and acronyms that the average employee may not recognize. For example, HIPAA policies might reference protected health information (PHI) without clearly defining what it includes, leaving employees to either undertake their own research or rely on personal interpretations. 
• Lack of Context: Policies may also lack the necessary contextual information to help employees identify when and where they apply. Imagine a compliance policy states, “all telemedicine consultations must comply with jurisdictional laws.” This statement, while important, lacks context because it does not clarify which jurisdiction it’s referring to. It could refer to the jurisdiction where the healthcare provider is located, the patient’s location, or perhaps where the providers’ electronic systems are hosted. 

2. Compliance Gaps 

Policies should be mapped onto existing regulations to ensure they cover all compliance requirements – but this is not how most healthcare organizations have historically operated. Instead, policies are developed ad hoc over several years – often written by different individuals or teams – and rarely consolidated or updated to align with changing industry concerns or regulatory standards. 

As a result, many healthcare organizations have apparent gaps in their compliance policies. For example, despite HIPAA’s ever-growing complexity, more than 50 percent of organizations have 16 or fewer HIPAA-related policies. Similarly, 37 percent of healthcare organizations do not have a cyberattack contingency plan in place, despite half having experienced an attack, and HIPAA having clear guidance to include such policies.  

3. Conflicting Policies 

Another result of ad hoc policy development is the risk of overlapping policies. Organizations may feature several policies that address the same challenge or behavior, often with slightly different phrasing or direction. This leaves employees to interpret how the two conflicting policies should be understood. 

Not only do conflicting policies create confusion, but they also undermine employees’ confidence in the Compliance Program. Employees may take conflicting policies or infrequent policy updates as a signal that the organization does not adequately prioritize or value compliance, leading to a weaker compliance culture.  

How to Write Effective Healthcare Compliance Policies  

The following four steps will help you effectively develop and implement policies that meet all compliance requirements and are clear to your employees: 

1. Audit Existing Policies 

Begin with a comprehensive audit of your existing policies to: 

• Pinpoint gaps where policies do not adequately address up-to-date compliance requirements. This might include AI compliance, evolving data privacy needs, or changing policies around specific operational areas like telehealth. 
• Identify conflicts between policies or areas where multiple policies could be consolidated to reduce the total number and make it easier for employees to follow them. 
• Evaluate the language, structure, and formatting of existing policies to establish how they could be made easier to parse for the average employee. 

This ensures you know exactly which new policies are required and how many policies can simply be updated or revised to improve comprehension and adoption. 

2. Leverage Pre-Existing Templates 

Developing new policies from scratch is time-consuming and expensive. Experts suggest a single policy could cost up to $5,000, a figure that does not account for the labor required to research, draft, conduct legal review, and obtain approval for the policy. A suite of 20-30 policies could therefore consume over $100,000 in staffing and consultant costs.  

Leaders can significantly reduce these costs without compromising on quality by using pre-existing policy templates. Companies like Compliance Resource Center offer a wide range of customizable templates that cover all relevant healthcare regulations and ethical concerns. These can be tailored to your specific organization and enable faster, more cost-effective policy production.  

3. Standardize Formatting 

Evaluate and standardize the formatting of your policies to create a clear and consistent experience for employees. Our experts suggest each policy should feature: 

• A short introduction and overview to make policies easier to understand. 
• An explanation as to why the policy exists, what it aims to achieve, and what legal or ethical requirement it is designed to meet. 
• Clear guidance and concrete examples to demonstrate how the policy should be enacted. 

4. Evaluate Language for Clarity 

Complete the process by going over the language in each policy with a fine-toothed comb, looking for ambiguity, technical jargon, and contextual gaps. The ideal process will include a sample of employees, asking for feedback to help understand how they respond to the language and whether policies are easy to follow. 

While this process should be iterative and collaborative, a few best practices include: 

• Use simple language and short sentences to improve readability and employee comprehension. 
• Use action verbs that encourage employees to act, not simply read the policy. 
• Explain any technical terms or acronyms, regardless of how obvious or widely known you think they may be. 

Replace and Enhance Your Compliance Policies with Compliance Resource Center 

Many healthcare compliance teams believe they lack the resources to fully overhaul their compliance policies, but Compliance Resource Center makes the process fast, simple, and cost-effective. 

Our customizable templates cover all healthcare regulatory requirements, including evolving areas like cybersecurity, HIPAA, and AI. This allows you to quickly create, adjust, and introduce new policies at a fraction of the time and cost it would take to develop them from scratch. 

Want to improve your compliance posture today? 

Contact Us 

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