committees went by different names (for example, health records, confidentiality, security, and information systems management) in different institutions and had different reporting structures. Some reported directly to upper management; others were part of a larger medical records committee. Regardless, committee composition is generally broad and may include members with knowledge of user needs and behavior (e.g., health information managers, nurses, physicians, admitting managers, human resources managers, and patient relations representatives), technical experts on the organization's information systems, lawyers, and patient representatives.14 Upper management often assists committee members by helping them to define a scope of work that complements rather than duplicates other organizational efforts and by requesting clear milestones for committee accomplishments. Using a committee structure to develop policy can be time-consuming and subject to delay; one site that had adopted a consensus decision-making style to ensure buy-in found the advantage offset by its time-consuming nature. Employees at this site commented also that committee memberships were often large (with members from each interested department) and subject to turnover, which further contributed to delay. Nevertheless, ensuring appropriate representation of interests is key to developing sound policy.

Structures for Implementing Policy

Once policies have been developed and approved, procedures are needed to translate their intent and goals into everyday practices, which may vary somewhat across departments. Whether or not the same individuals or committees that developed the overarching policy take on or delegate the task of developing procedures is not as important as ensuring that authority and responsibility for implementation are clearly assigned. Responsibility derives from accountability: unless management makes it clear that responsibility has been delegated, no one may assume responsibility, and employees may not know where to go with questions or problems. Accountability is particularly problematic in organizations in which committees formulate policies but individuals or departments are charged with policy implementation.

Several of the sites visited by committee members had designated an


Another goal of broad committee membership is to include both system users and system designers. Input may be sought from the broader population as well by means of "comment boxes" into which users can drop suggestions for policy changes or system redesign. Also important is ensuring that the concerns of patients are met. In the sites visited by the committee, organizations often charged legal counsel with representing patient concerns. Other options include community representatives on key committees or active solicitation from the community via open meetings or annual surveys.

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