Policy review preparation

Healthcare practices evolve, new EHR systems are adopted, workflows change, staff turns over, new services are added. Policies that do not keep pace with these changes create a gap between what is documented and what actually happens in the practice. This gap is a compliance risk: if a review or SRA reveals that policies describe workflows that are no longer followed, or do not address systems that are now in use, the practice may need to address both the documentation and the underlying operational reality.

Before any review can be meaningful, the practice needs to know what policies it currently has. Many practices have policies that were created at different points in time, stored in different locations, and managed by different individuals. Bringing all relevant policies into a single, organized repository, even just a shared folder with a clear naming convention, is the first step in making review manageable.

• Create a policy inventory listing every current policy, its version date, and its owner
• Identify the location where each policy is stored, digital, physical, or both
• Note any policies that have not been reviewed in more than two years
• Identify any policy areas where documentation appears to be missing
• Confirm that all policies include a review date and version number

A policy review involves comparing each policy against current practice operations to identify discrepancies, outdated procedures, and missing elements. The review should ask: Does this policy reflect how the practice currently operates? Are the systems referenced still in use? Are the role titles and responsibilities accurate? Has the regulatory or operational environment changed in ways that require policy updates? Every identified discrepancy is a potential remediation item.

• Confirm that policy language reflects current systems, software, and workflows
• Verify that role titles and responsible parties in policies match current staff structure
• Check that policies address all current ePHI systems, including recently added ones
• Identify policies that reference deprecated systems or workflows and flag for update
• Review policy language for clarity, ambiguous policies are difficult to follow consistently

Policies identified as outdated or incomplete during review should be updated before the review cycle closes. Updates should be reviewed by appropriate personnel, typically practice leadership and, where the content involves compliance or legal considerations, by appropriate advisors. Updated policies should be versioned, dated, and distributed to applicable workforce members, with acknowledgment of receipt documented where required.

Not all policy gaps require equal urgency. Gaps in policies that address high-risk areas, breach response, access termination, or incident reporting, should be prioritized over gaps in lower-risk administrative policies. Documenting the prioritization rationale supports the practice's ability to demonstrate a structured approach to policy management.

The policy review process itself should be documented. Documentation should include who participated in the review, when the review was conducted, what policies were reviewed, what changes were made, and who approved the updated versions. This record supports the practice's ability to demonstrate, during an SRA, audit, or inquiry, that its policies are actively managed and that review cycles are completed on schedule.

• Create a review log that records the date, participants, and scope of each policy review
• Document each policy update with the reason for the change and the approving party
• Archive prior versions of updated policies for the six-year HIPAA retention period
• Distribute updated policies to applicable workforce members and document distribution
• Schedule the next review cycle at the time of each completed review