Organizational Risk Associated with Poor Policy Management: Building a Compliant Document Control Process

ASHRM On-Demand Webinar
Member: $39.00
Non-Member: $99.00


CE Credit: 1

Domain: Leadership

Level: Foundational/Practitioner


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This session will cover the critical risk elements of policy management and document control in health care.

This session will cover the critical risk elements of policy management and document control in health care. The speaker will provide some insight into why it is a regulatory requirement for organizational leaders to have appropriate practices in the implementation of policies and how those practices help to mitigate risk, inhibit conditional level findings by regulatory organizations like CMS and meet targeted patient safety outcomes. By implementing a well-developed policy structure there is diminished organizational risk in litigation. There will be a discussion of how a standardized document control process and approval workflows ensure standards are met and thus decrease the possibility of medical negligence. This leads into the policy management structure and how a compliant document control process can enhance an organization's strategic foundation. There will be a review of a Preventive Risk Analysis and how these types of tools can help align required regulatory documentation with efficient document control and ensure best practice is utilized. Discuss how regulatory bodies view the leadership role related to effective policies and how they should be the driving force in proactively moving well-developed and evidence-based policies forward, enabling staff to easily access the guiding principles of the organization and proactively utilizing policies as a communication tool. There will be a review of how advisory committees such as the CDC view the use of guidelines to provide appropriate care, treatment, and services.


  • • Provide insight into why appropriately standardizing and implementing policies and procedures assists organizational leaders in negating risk litigation
  • • Identify foreseeable risk associated with suboptimal document control
  • • Discuss how standardizing document control assists in meeting regulatory accreditation compliance
Speaker: Tina Nelson, RN, MSN, MBA, Regulatory & Accreditation Specialist for MCN Healthcare
Product Code 322015OD20
ASHRM CE Credits 1.0
CNE Credits 1.0
Domain Leadership
Level - Foundational (F), Practitioner (P), Advanced (A) F/P
Publication Date 12/10/20
Next Review 7/1/24
Credit Expires 7/1/25

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Speaker Bios


Tina Nelson RN, MSN, MBA, has 35 years of nursing and healthcare experience performing leadership roles in research, emergency and intensive care nursing, long term acute care and behavioral health care. For the past 20 years, she has specialized in post-marketing surveillance of new FDA approved cardiac biomarkers, quality and performance improvement, regulatory accreditation consulting, and content writing. She has received numerous awards in innovative quality and performance excellence. She has helped hospitals achieve success in regulatory and State certification, policy management, performance improvement, and a reversal of organizational conditional level findings and immediate jeopardy.