Mitigate Risk and Protect Your Organization: Automating Policy Management and Conflict of Interest Disclosure

October 28, 2022
October 28, 2022
10.19.22-Mitigate-Risk - Doctors reviewing paperwork

This blog is taken from a recent HealthStream webinar titled “Mitigate Risk and Protect Your Organization: Automating Your Process for Managing Policies and Conflict of Interest Disclosure.” The webinar was moderated by Jaclyn Franklin, HealthStream’s Product Marketing Coordinator and featured Jennifer Stoop, Senior Product Manager, Quality and Compliance and John Mate, Director of Sales, Quality and Compliance.

The webinar focused on the ways in which healthcare leaders can reduce risk and allow staff to spend more time on high-priority tasks by managing policies and conflict of interest (COI) disclosures in a much more efficient way.


Policy and Procedure Management – Why It Matters and How to do It Better

Mate began by reviewing the purpose of healthcare policies and procedures. There are literally hundreds of healthcare policies and procedures all serving a central purpose – to ensure safe practices and predictable outcomes while mitigating risk. They do this by establishing rules, enforcing regulations and standards, and defining standards of care.

Because there are so many policies and procedures, healthcare organizations need effective ways in which to manage them. “At a minimum, healthcare organizations need to have a systematic process for ensuring those policies and procedures are up-to-date, reviewed and approved by key stakeholders. In addition, they need to be revised as necessary and distributed to staff and that older versions are removed and properly archived,” said Mate. 

The process for manually managing the process with paper and binders is daunting and fraught with potential problems. This approach can result in policies with lost or missing pages, difficulty in tracking and managing revisions and increased risk of fines and litigation. The process is simply too large and too complex to be successfully managed with manual processes.


Policy and Procedure Management – The Right Tools

The right tools can make this overwhelming task more manageable while reducing risks to patients and to the organization. HealthStream’s Policy Manager automates the process and helps ensure that policies are correct, current and readily available to your staff. Mate shared that Policy Manager automates all aspects of policy management. The system can track and manage all revisions, provide detailed audit logs of those changes, and provides an easy-to-use search feature that allows users to access the documents that they need. In addition, Policy Manager will organize and distribute policies. Policy Manager also provides policy attestation and allows users to add quizzes to ensure comprehension. This solution also provides reporting to help leaders feel confident that policies are current, have been distributed to and have been read and understood by staff.


Conflict of Interest Disclosure Management

Effective management of conflict of interest (COI) disclosure is equally vital to ensuring compliance. Unfortunately, it can be equally complex and time-consuming without the right tools. Stoop began by sharing the various elements of an effective COI program. She shared that the foundation of a solid COI program begins with the culture of an organization from the top down. Other elements include:

  • Awareness and education: Is everyone aware of what constitutes a conflict of interest and what needs to be disclosed. How often are staff being trained on policies?
  • Policy development: the process for developing policies and determining what needs to be disclosed
  • Disclosures: do employees understand the process for making a disclosure?
  • Disclosure management: is there an effective process for managing the disclosures?
  • Reporting and Actionable Data: are disclosures being managed in such a way that will facilitate actionable reporting?
  • Continuous improvement: once the data has been collected and reported, is it being used for performance improvement?


Conflict of Interest Disclosure Management – Automating the Process to Reduce Risk

Traditionally, the entire process has been managed with paper surveys or online survey tools that were cumbersome to manage and made it difficult to ensure full compliance. Stoop encouraged the use of technology for a more refined and disciplined approach to COI management. HealthStream’s Conflict of Interest solution automates the COI disclosure and management process. Stoop shared that HealthStream’s COI management system fully automates processes such as emails that will automatically track who has (and has not) completed their surveys and emails that follow-up with reminders for those that have not. “This solution is going to allow you to increase your bandwidth and allow you to spend more time managing the disclosures that represent true conflicts,” said Stoop.

In addition, the system offers improved data visualization through the use of dashboards that provide accurate, actionable data. It can also be used to identify operational inefficiencies and bottlenecks in the COI process. The dashboard-style reports include metrics such as past-due questionnaires, management plan status, and the number of assigned and submitted reports. “HealthStream’s COI solution allows users to spend less time on the time-consuming, resource-intensive tasks, such as tracking down surveys and allows leaders to focus on evaluating the entire process and, most importantly, taking action on the data,” said Stoop.

In addition, Stoop shared that the Conflict of Interest solution is integrated with the CMS Open Payments database. The solution ensures that the data from your staff matches the publicly reported data that users can access in the Conflict of Interest Solution.