The Importance of Internal Company Documents, SOPs, Policies and Procedures

By: Pearl Walia

Healthcare organizations are responsible for implementing appropriate training and internal procedures to facilitate a high-quality and compliant environment. Quality of care is not limited to the medical services or products provided to patients; it also stems from the way the employees perform their duties, and the work process they follow. The work processes should be continuously monitored and adapt to the evolving operational requirements and trends in healthcare.

Standard Operating Procedures (SOPs)

Standard Operating Procedures (SOPs) are detailed written instructions that explain how employees should conduct routine business processes. SOPs help simplify complicated processes into manageable steps for employees to perform their duties more efficiently.

In the healthcare industry, where there is a widespread use of technical language, complex workflows, and heightened standards of care, SOPs are especially necessary. Consistency with patient care is key and having standard and understandable procedures in place for employees to follow is important to ensure that employees do not overlook basic steps that can lead to patient injury, treatment delays, medication errors or other consequences.

SOPs are also useful in onboarding new employees, regardless of their experience level, by holding them to the same organizational standards and expectations as other employees. However, it is key for organizations to recognize that SOPs should not remain static; they must be reassessed and updated as governing standards in healthcare continue to evolve. For example, as data privacy laws change, organizations are advised to keep up with the changes and adjust their patient data retention policies and informed consent policies accordingly. Similarly, it is key to periodically reassess best practices and technology that may be outdated or ineffective.

Internal Company Documents

A company’s internal documents are the materials employees rely on to perform their jobs effectively. Some examples of these documents include the company’s SOPs and employee handbooks. Employee handbooks outline the company’s mission, employee expectations, and employee benefits and responsibilities. They provide employees with a written guide on their expectations and rights. Internal company documents can also include safety manuals which contain organization-specific protocols for employees and management to ensure a safe workplace. Essentially, internal company documents refer to any materials that assist the team in carrying out their responsibilities efficiently. Unlike advertising materials or manuals distributed to clients or the public, these documents are solely for organizational use.

Best practices for Internal Company Documents

Organizations are advised to establish protocols governing the collection, sharing, and storage of all internal company documents, especially those which align with the norms of the Health Insurance Portability and Accountability Act (HIPAA) and other similar regulations. This is especially important when involving the storage, retention, and sharing of protected health information (PHI) and other sensitive data. It also includes procedures for incident reporting, implementation of corrective actions, and addressing ways to prevent future breach of protocol. The ultimate goal is to communicate to employees the policies and procedures of the organization in the most thorough and understandable way to ensure the safety of the patients and the organization, and help reduce liability in the event of disputes or litigation.

Policies and Procedures

Policies and procedures of an organization can be implemented across multiple operations, including administrative, human resources, information technology, and patient care. An organization may have policies and procedures in place in the following ways:

● Accreditation requirements: Accreditation can improve credibility and can serve as a competitive advantage of the provider within the industry.

● International Processes: Communication between staff members and patients, family members, and all other parties should be regulated with strict policies on confidentiality, informed consent, and consistency in patient communication.

● Patient Safety: This involves standardizing patient care processes to ensure there is full transparency and immediate communication with patients regarding charting and medication changes. This also includes implementing policies and protocols for emergency situations.

● Infection Prevention and Control: Due to the increased risk of exposure to infectious diseases in healthcare settings, it is advised for organizations to implement infection control policies to prevent outbreaks.

● Documentation: Although there is no policy that is capable of eliminating liability, strong documentation can help mitigate liability. Documentation of all employee records, patient records, and other documentation practices help in ensuring accountability and potential mitigation of liability in the event of audits or lawsuits.

How Often Should Policies and Procedures be Reviewed and Amended?

Healthcare policies should be reviewed regularly, such as on an annual basis. They must be also reviewed or amended to reflect changes in industry regulations, technological advancements, or standards. Simply put, they should not be outdated, ineffective, or overlooked. Healthcare organizations can benefit from periodically consulting legal counsel to review their operational practices and ensure they remain aligned with their goals. Regular assessments can help identify any gaps in compliance or other issues that may be limiting organizational growth. To support this process, our firm will soon be launching an Annual Legal Diagnostic service where clients will have the opportunity to share their current operational practices and business goals with our team. We will evaluate their existing practices and develop tailored strategies to align their operations with their long-term goals.

SOPs, Internal Company Documents, and Policies and Procedures of Organizations reflect the backbone of the organization’s compliance and operations. Due to the highly regulated nature of the healthcare industry, organizations are advised to be proactive in reviewing these protocols and ensuring through communication and transparency with all employees to optimize patient safety.

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It should be noted that I am not your lawyer (unless you have presently retained my services through a retainer agreement). This post is not intended as legal advice; it is purely educational and informational, and no attorney-client relationship shall result after reading it. Please consult your own attorney for legal advice. If you do not have one and would like to retain my legal services, please get in touch with me using the contact information listed above.

All information and references to laws, rules, regulations, and advisory opinions were accurate as of this time, but laws are constantly evolving. Please get in touch with me to ensure that the law governing your business is up to date. Thank you.