Risk Management Best Practice 3 – Procedure Annotation and Commitment Tracking

Maintaining compliance with regulatory requirements, industry guidelines, and organizational commitments is the responsibility of every employee. Compliance typically occurs on a day-to-day basis through the performance of common policies, processes, and procedures. Subsequently, most organizations embed the actions necessary to achieve compliance within their instructional manuals. Ensuring these actions are both followed and remain in place over time is key to a successful compliance program.[wcm_restrict plans=”49014, 25542, 25653″]

Driving personnel compliance with written procedures is a reinforcement function of management covered by several StrategyDriven topic areas including Management and Leadership, Management Observation Program, and Self Assessment Program. The other critical step in ensuring compliance is the maintenance of those steps within policy, process, and procedure documents, which is the focus of this article.

Maintaining compliance activities within their respective documents over time is a difficult task. These requirements are frequently administrative in nature, burdensome, and the source of inefficiency. Thus, they routinely become the target of streamlining to improve overall productivity. And while compliance activities should be performed in the most efficient manner possible, they must none-the-less be performed. Therefore, it is important to provide a mechanism that will help ensure these activities remain intact within a given procedure.

Keeping compliance activities intact while simultaneously providing opportunities for review and possible streamlining requires identification of both the activity and the source requirement, guideline, or commitment. One highly effective mechanism to achieve this is to label those particular policy, process, and procedure sections related to a given requirement in a way that clearly links the two. Companies creating such a system typically perform the following activities:

1. Identify all regulatory, industry, and organizational requirements.
2. Logically catalog the requirements; providing each requirement with a unique alphanumeric index designator and a listing of the associated policies, processes, and procedures used to satisfy the requirement.
3. Identify all those policy, process and procedure sections/steps in place to ensure compliance with each given commitment.
4. For policies: Identify, in an appendix, all those commitments for which the policy satisfies. For each commitment, provide a brief narrative of those policy aspects that serve to satisfy the requirement.
5. For processes and procedures: Identify the specific process and procedure steps required to satisfy the commitment. Label these steps in the left margin with the alphanumeric designator of the requirement. Create an appendix listing the requirements associated with that procedure. The listing should include both the requirement name/title, requirement alphanumeric designator and process/procedure step(s)
6. Update monitoring program documents to drive active reinforcement of the requirements, guidelines, and commitments. (Note that these documents should be treated as procedures.)
7. As new regulatory requirements and industry guidelines are issued or commitments entered into, update the commitment catalog and appropriate policies, processes, and procedures in accordance with Steps 2 – 6.
8. When updating policies, processes, and procedures, require reviewers and approvers of the changes validate that no requirement satisfying actions were inadvertently eliminated or diluted such that compliance is no longer maintained.

This system clearly links organizational practices and activities to the company’s commitments, thereby, bringing attention to those practices that must not be eliminated or diluted while at the same time affording individuals an opportunity to compare the practice to the requirement to enable identification of compliance-maintaining efficiency improvements.

Final Thought…

While the practice of cataloging requirements and linking them to policies, processes, and procedures helps ensure the organization continues performing those activities necessary to meet its obligations, it is by no means a foolproof system. Therefore, StrategyDriven recommends the index of commitment requirements be used to periodically audit the organization’s policies, processes and procedures to verify compliance activities have been maintained and to also review those personnel performance evaluation programs ensuring enforce activity performance.[/wcm_restrict][wcm_nonmember plans=”49014, 25542, 25653″]

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