When the Unexpected Happens: The Importance of Policies and Procedures

Providing specialized consultation in the field of addiction treatment risk management is an essential function of our organization. We see firsthand that providers supporting the treatment and recovery of substance use play a critical role in maintaining the safety of each individual seeking care It is not uncommon for these individuals to feel emotionally and physically vulnerable when seeking substance use treatment. An unfortunate reality is that an unexpected event, such as the one outlined below, could occur when organizations do not implement comprehensive internal controls through comprehensive policies and procedures:

Sally Whitaker Bergquist

Sally Whitaker Bergquist

A twenty-four-year-old male is admitted to a residential treatment provider for substance use withdrawal. The day after admission, he was found by staff to be unresponsive in his room. Resuscitation efforts are attempted but not successful. It is an event many professionals fear and dread in their human service role.

One significant role of care providers is to recognize the risk of harm, assess the risk, and implement proper procedures to maintain patient safety. When an unexpected event occurs, such as the example above, the organization’s written policies and procedures should be reviewed by the leadership team. They may also be reviewed by the state’s accrediting/licensing agency, the plaintiff’s attorney representing the deceased client, and the defense attorney representing the insured organization. Organizations should take the time to ensure their policies and procedures follow state guidance and meet best practice criteria.

When incidents occur, organizations are held to the precise standards they have in effect at that time. Be sure your policies and procedures are strong.

Over time, the standard of care is sure to evolve to best provide the highest quality of service delivery. Changes in healthcare, culture, and technology can impact these standards. As your policies adapt to comply with the updated standard of care, it is important to keep a record of any policies that have been modified or updated. This should always include the dates the preceding policy was in effect. With so many policies online, there may be a tendency to update and hit “save,” but it is important to remember to always keep a copy of the original policy to verify the standard of care in existence at that point in time.

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When developing written policies and procedures, consider the standard of care or how things are performed in your local area. For example:

  • How do other organizations in your area that provide the same or similar service perform this activity?
  • How does your state licensing agency view this activity?
  • What are the state laws or regulations?
  • What does the Department of Public Health require for these patients?

Finally, consider the requirements of Federal or national agencies. What are the requirements of the Centers for Medicare and Medicaid for an organization such as yours? What does your professional organization recommend?

One of the other most important aspects of policies is employee compliance. It is crucial for your employees to realize the importance of policies and not to simply do what they have always done over the years. If the organization has well written, detailed policies, but a review of events determines your employees are not compliant with the policy, it is important to delve into the issue. Ask why there is non-compliance. Questions to consider might include:

Do employees know how and where to find the current policy?

  • Are policies accessible to them online?
  • Do employees know where the current policy is located and how to access the policy 24 hours per day/7 days per week?

Are the policies up to date?

  • How are employees informed of policy changes and new policies?

Are your policies realistic?

  • Is there a need for additional education, different equipment, or additional training on equipment? Be sure your employees can comply with the policy as written.

Are your policies too detailed?

  • An overly detailed, complicated 30-page emergency response plan will not be helpful for employees overseeing a high-stress situation. Keep it manageable.

Ultimately, internal controls are the first line of prevention for all providers, especially in the addiction treatment space. Written policies and procedures should be referred to frequently and should function as a road map for your organization. They should be relevant and up to date. A review process should include assessing any incident trends that occurred between reviews. This could identify an area that is uncovered by the current policies and procedures. Ensure your employees know where to locate this information and are notified of any updates or changes.

Sally Whitaker Bergquist is Senior Risk Management Consultant  at Irwin Siegel Agency.

Irwin Siegel Agency has become synonymous with expertise and customized programs for Addiction Treatment and Behavioral Healthcare Providers since its inception in 1960. We are pleased to offer a comprehensive insurance program through an A++ rated global insurance company. As a Program Administrator, ISA strives to provide tailored property and liability insurance and risk management solutions that meet the unique needs of organizations like yours. We work directly with your current agent or broker! To learn more, call 800.622.8272 or visit siegelagency.com.

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