PRESENTATION ON HOSPITAL MANAGEMENT POLICY

~MIRIAM N. CHRISTOPHER~
2022

TABLE OF CONTENTS

Chapter 1: Introduction

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Chapter 2:

Chapter 3:

Chapter 4: Policy Objectives and Orientation

Chapter 5:

Chapter 6:

Chapter 7: Conclusion

Chapter 8: References

CHAPTER 1

INTRODUCTION

The population in various countries is increasing rapidly every year, and a lot of
people have seen the need of health care. Health cares are one of the most essential
needs of a man. It is a necessity according to Agnes (2011) at the University of
Nigeria; the hospital is an institution for health care that provides patient treatment
by specialized staff and equipment. Hospitals are largely staffed by professional
physicians, surgeons, and nurses. It is a place where patients visit for medical
checkup or treatment. Hospital workflows are done within twenty-four hours. Due
to this reason, the hospitals need efficient management. According to Toussaint

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(2015), hospitals can’t improve without better management systems. In Toussaint’s
perspective, management is a significant part of today’s cost and quality crisis in
health care. This is the reason why suitable hospital needs and appropriate medical
management must be present to deliver applicable healthcare facilities.

To create and sustain high-quality patient care, healthcare facilities rely on

effective guidance from a variety of results-driven, health-related policies and
procedures. These policies provide a framework for employees by outlining
expected standards for day-to-day operations and help facilities meet the many
health, safety, and legal regulatory requirements in a high-risk industry.

The ultimate goal? To provide safe, high-quality patient care, achieve quality
goals, efficiently use resources, and lessen risk in the process.

Written policies and procedures help healthcare facilities in a number of ways.

They help mitigate risk by ensuring facilities comply with ever-changing rules and
regulations, guiding employees with best practices in care delivery, securely
handling sensitive documents, protecting staff from potential harm, and working to
avoid costly lawsuits.

They improve compliance to industry standards by requiring healthcare

organizations to meet complex accreditation requirements, and federal, state, and
local laws and regulations.

And they improve internal communication by ensuring that staff members have the
information they need to do their jobs well, which makes operations run smoothly
and fosters better patient care.

CHAPTER 2

HOSPITAL MANAGEMENT: SCOPE & CONCEPT

Hospital management plays a vital role in the health care sector, keeping health
care institutions running and providing consistent quality of service. They ensure
that hospitals and other health care facilities provide the best care for each patient.
Health care facilities have job opportunities for both hospital management
graduates and people from other academic backgrounds.

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Hospital Management is all about the planning, implementation, coordination, and
operational management of hospitals, health care facilities, or clinics. It relates to
the proper management of all the operations of a hospital ranging from patient care
to medical record-keeping, ensuring the availability of medical supplies and
medical equipment to maintaining sanitary standards and other important
functions.

Professionals involved in hospital management oversee all the elements of hospital

administration. They manage, supervise, and evaluate work activities of medical,
nursing, technical, and other personnel. Apart from managing and controlling
major functions in a hospital setting or a healthcare facility, hospital managers also
engage with the doctors and surgeons to determine the most efficient and most
favorable methods of supporting patient care delivery.

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 POLICIES

1. PATIENT CARE

The first place to start with health policy examples covers those designed for
patient care. A one-size-fits-all set of patient care policies will not work, as every
facility’s needs are different based on the type of care it provides.

Whether your facility is a multi-state hospital, a small podiatry practice, or a

regional rehab center, you should have facility-specific policies that cover the way
in which your facility cares for patients.

For example, effective policies should address what types of procedures your
facility performs, what types of illnesses and injuries your facility treats, when to
refer patients to other facilities, and when to transfer them. More specifically, your
patient care policies should explain how to handle particular medical situations,
such as exposure to bodily fluids or medical emergencies.

Regardless of your organization’s size or type of care provided, a good first step
with patient care policies involves asking key questions that relate to your specific
facility.

While some of this may seem obvious, it is better to err on the side of caution by
including potential issues and areas of concern in the beginning rather than coming
across a problem later. It really means taking a more proactive rather than reactive
approach.

Learn more about developing patient care policies for your facility.

2. WORKPLACE HEALTH AND SAFETY POLICIES

With patients at the heart of your health-related policies, it makes sense then to
include a variety of policies that cover your biggest asset – namely, employees.

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As the number one resource of any healthcare facility, employees need (and
deserve) policies that look out for their health and safety on the job. This holds
especially true because healthcare professionals face much greater health risks
compared to most other industry professions.

Depending on your specific healthcare facility, you might need employee policies
that cover issues such as personal protective equipment (PPE) (i.e., when do they
need to wear gloves, masks, or more); exposure to substances like chemicals,
infectious agents, or drugs; and any physical hazards in and around your facility.
Your policies and procedures can help make employees aware of these hazards and
protect their health.

But beyond that, do not overlook the overall wellness of your staff. Do you
have programs or policies to promote and protect their wellness?

Just as in other industries, your wellness policies should address concerns like
weight loss, work stress, healthy eating, and even on-the-job breastfeeding. All of
these contribute to a healthy workforce, which research continues to prove is a
more effective workforce.

Learn more about workplace health and safety policies.

3. INFORMATION SECURITY POLICY 

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The issue of security is becoming an increasingly important one for healthcare
facilities of all sizes. Even for smaller organizations that lack a dedicated security
team, how will they handle suspicious persons or situations? When do they sound
an alert and to whom?

Whether your facility maintains a security team or not, your health-related policies
should clearly explain that security, like compliance, is everyone’s responsibility.

You need to equip employees at every level with the right information and
procedures so they can handle security-related situations that might arise.

4. DATA PRIVACY AND IT SECURITY

Increasingly, data privacy and IT security are connected in terms of hospital

policies and procedures. The more technology you incorporate into your facilities,
the more risks you face for data leaks or privacy breaches.

At the core of these leaks? Primarily, human error falls at the crux of these
breaches. That is why it is crucially important to put in writing these security and
privacy policies. They can help your facility avoid a costly error.

For example, the consequences of not complying with HIPAA could mean losing

your tax-exempt status by failing to comply with new requirements from The
Patient Protection and Affordable Care Act. Or noncompliance could mean facing
a stiff fine.

According to HIPAA Resolution Agreements from the Department of Health and

Human Services (HHS) Office for Civil Rights (OCR), HIPAA fines can be up to
$1.5 million per incident per year.

Learn more about writing your patient data privacy policy and how to create
effective HIPAA policies and procedures.

5. DRUG HANDLING

What procedures and safeguards are you putting around drug handling? Many
facilities do not carry medicines in-house, while others only carry over-the-counter
drugs, and still more carry very controlled and regulated drugs.

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Regardless of where you fall on the spectrum, you need very clear policies on how
you administer medication, how you record and chart it, and what to do if an error
occurs or inventory goes missing.

6. ADMINISTRATIVE AND HR POLICIES

Another category of health policy examples includes administrative and HR

policies. These cover all of those aspects of running the facility from a business
and personnel perspective.

While caring for patients and helping them heal drives the mission of healthcare
facilities, it is important to remember that they are still a business and need to
operate effectively.

And, like any other business, these facilities also need policies that address general
HR issues such as dress code, vacations, sick days, and shift-changes. Plus, these
policies should address more health-related administrative issues such as patient
visitation and bed capacity.

These seemingly mundane policies and procedures can help streamline many of the
questions and concerns and help administrative staff more efficiently run the
operational side of things.

7. SOCIAL MEDIA POLICIES

The lure of Facebook and Twitter can pose some complex challenges when it
comes to social media and healthcare. What are employees allowed to post when at
work? What about when they are off duty but talking about things that happened at
your facility?

A fine line exists between protecting the interests of the facility, the patients’
privacy, and the employees’ First Amendment rights. That is why you need a
written policy that clearly spells out what is and isn’t allowed by employees.

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A well-crafted social media policy in healthcare should touch on employee access,
use of official accounts, online conduct, security requirements, disclaimers, and
engagement.

Outlining these details can help your facility proactively prevent scandals such as
an employee tweeting something offensive from an official hospital account or a
staff member sharing confidential facility information online.

A social media policy can also help you effectively address and defuse problems
that do arise before they do too much damage.

8. BYOD POLICY

Common health-related policies often include a bring-your-own-device (BYOD)

policy, which can be very simple and straightforward depending on your facility’s
needs.

Everyone owns a smartphone these days. These personal devices, while helpful,
also carry their own unique risks, especially when it comes to accessing sensitive
work information. This doesn’t necessarily have to mean patient information; it
could also mean work emails and communications or internal files and documents.

The lines between work and home are blurred these days, so creating a BYOD
policy helps define what your organization does and does not allow on personal
devices.

It doesn’t have to be overly complicated, but your BYOD policy should focus on
those areas that pose the biggest potential risks to your facility.

9. INFECTIOUS DISEASE POLICY

An infectious disease policy is the set of guidelines, rules, and regulations that
establish the importance of disease control and how to prevent an outbreak.

Healthcare workers have a higher risk of contact with infectious diseases than most
other industries. It comes with the territory.

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An infectious disease policy keeps your employees prepared and informed on best
practices and regulations. This prevents diseases from spreading, keeps healthcare
workers safe, and protects your organization from liability.

According to SHRM, “Employers are legally liable for both employees and
nonemployees infected in the workplace."

There are several key steps to developing your infectious disease policy:

1. Identify known risks

2. Plan for unknown risks
3. Create a communication plan
4. Assign roles
5. Comply with regulations
6. Train your employees

To learn more about developing your policy, visit our article Infectious disease
policy in healthcare.

10. CODE OF ETHICS

With healthcare being such a complex, high-risk, evolving industry, you will never
be able to write enough health-related policies to cover every situation. Therefore,
adopting a code of ethics policy will help determine the type of principles,
behaviors, and ethics you want employees to demonstrate in every circumstance.

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This organizational culture is not something you can mandate in a written
document. However, you can codify and put words to a culture of respect, honesty,
fairness, accountability, and compliance that your facility aims to develop.

Creating a culture of accountability in your healthcare facility starts with

leadership and trickles down throughout the organization to employees at every
level.

It helps you focus on your shared purpose and makes employees aware of
expectations. And it fosters open communication from top to bottom. This
empowers everyone to understand your organization’s goals, your mission, and the
values you want every employee to demonstrate.

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