Skip to content

Policies and procedures for hospitals

Written, approved, acknowledged and reviewed on time, with a record a surveyor can read. Nothing lapses quietly.

What a survey-ready library looks like

Every one numbered, owned, approved, and dated for its next review.

The binder problem

A hospital runs on hundreds of policies. Most are kept in a way nobody would choose.

  • Shared drives and email

    Three versions of the same policy, and nobody sure which one the unit is following.

  • Approvals by signature sheet

    Signed, scanned, filed. When the surveyor asks who approved the restraint policy and when, someone goes looking.

  • Review dates in a spreadsheet

    Kept by one person. Discovered to be out of date by a surveyor, or by an incident.

  • Acknowledgement by assumption

    "Staff have been made aware." Of which version? Which staff? Since when?

How a policy lives here

One loop, and the record writes itself.

  1. 01

    Written

    An author uploads the PDF or Word file, or writes it here. It has a number, a department, a review cycle. Nobody else sees it yet.

  2. 02

    Sent for approval

    The approval workflow takes it: the department, then the approver, then whoever the hospital’s chain requires. Each decision is a signature with a name, a title and a time.

  3. 03

    Approved and published

    The last signature publishes it. Staff see it that moment; the previous version is kept, read-only, forever.

  4. 04

    Acknowledged by the right people

    Everyone it applies to is asked to read it and say so. Reminders chase the ones who have not, and their manager sees who is overdue.

  5. 05

    Reviewed before it lapses

    Ninety, sixty and thirty days before its review date the owner is reminded. A policy that lapses is a finding; here it is a task that arrives on time.

POL-2026-014v3.2

Hand Hygiene

Draft · not yet seen by anyone

Next review

What is in it

The core is the policy loop. The rest is what a compliance office asks for next.

Policy library

Numbered, filed by department, category and type, searchable by full text. Every version kept.

Approval workflows

Whatever the chain is: department review, then approver, then administrator. Signatures with names and times. Stalled approvals chased weekly.

Acknowledgements

Assigned by everyone, department or role on publish. Reminders, overdue reports, a record that answers "who has read this?"

Review cycles

A date on every policy, reminders at 90, 60 and 30 days, an overdue list for the administrator.

Audit log

Who did what, when, to which record. Exportable. Retained.

Add-ons

Scope of Service, Forms & Attestations, Competency & Training, Exceptions & Variances. Switched on per organization.

What each one does
0

days before a review date the first reminder goes out, then at 60 and 30

0 min

is how long a sign-in link lives. No passwords, nothing to reset

0

passwords for hospital staff to manage, ever

Getting in

A link in their email, or their Microsoft account. Never a password.

Staff type their work address and get a sign-in link. Hospitals on Microsoft Entra ID turn on single sign-on and staff use the account they already have. The hospital’s own System Admin runs it, and always keeps a way back in.

Security and sign-in
Sign in
d.reyes@mercy.org
Continue with Microsoft
Email me a sign-in link instead

What a nurse at a hospital with single sign-on sees. Both doors work; the hospital chooses when to close the second.

The standards a policy library answers to

  • The Joint Commission
  • CMS Conditions of Participation
  • DNV NIAHO
  • HIPAA
  • CAP
  • AAAHC
  • State Departments of Health
  • OSHA
  • HFAP
  • NCQA

See it with your own policies.

A demo takes half an hour. Bring three of your policies and we will walk one of them through the loop, end to end.