Rewriting the Rules: Using AI to Transform Hospital Policy Writing

Rewriting the Rules:

Using AI to Transform Hospital Policy Writing

Meet Sarah, a Quality Assurance Director at a 400-bed regional hospital.

Every month, Sarah faces the same overwhelming task: reviewing dozens of hospital policies for compliance updates. She begins by digging through hundreds of pages of CMS guidelines, Joint Commission standards, or DNV requirements. Then she layers in OSHA, CDC, FDA, and recommendations from one or more of the 120+ national medical specialty societies.

But here’s where it gets complicated.

Once Sarah collects all the standards, she must decide what belongs in a policy versus what should live in supporting documents. Should the medication management policy include step-by-step instructions for IV prep? Or should that detail live in a nursing protocol? Should infection control policies include cleaning checklists, or should those stay in department guidelines?

Hours pass. Sarah is still wrestling with these decisions—struggling to balance regulatory compliance with practical readability. Sound familiar? She’s not alone. Healthcare administrators everywhere face the same challenge. But what if there was a better way?

The Hidden Problem: Policy Writing Is Three Jobs in One

Policy writing isn’t just “writing.” It’s actually three demanding jobs rolled into one:

1. Research overload. Every infection control policy may draw from dozens of sources—CDC guidance, OSHA rules, state regs, and accreditation standards—and it’s hard to keep track of what’s current.

2. Structural puzzle. What belongs in the high-level policy, and what needs to move into a protocol, procedure, or guideline? Too vague, and the policy is useless. Too detailed, and it’s unmanageable.

3. Clear, compliant writing. The final draft has to be readable for frontline staff, rigorous enough for regulators, and structured to support consistent patient care.

Most administrators tackle all three manually. No wonder it feels impossible.

How AI Changes the Game

Generative AI can transform this process by tackling each of these jobs directly:

• AI handles the research. Instead of scanning hundreds of pages, AI can identify exactly which requirements apply and explain how new standards affect existing policies.

• AI solves the structure puzzle. It can recommend what belongs in the core policy and what should shift into protocols or guidelines. Example: keep high-level safety rules in the policy, move prep steps to nursing protocols, and drug specifics to pharmacy procedures.

• AI drafts clear content. The output balances compliance with practical clarity—policies that regulators accept and staff can actually use.

The Health System Policy Assistant

To make this real, I built the Hospital Policy Assistant for Health Care Systems, powered by ChatGPT’s latest GPT-5 Thinking model. It runs an ~1,000-word system prompt and helps teams draft, align, and review policies fast. Here’s what it does:

• Identify the standards relevant to your policy topic.

• Analyze a draft and separate what belongs in the policy from what should live in protocols or guidelines.

• Map each line of your draft to the applicable standard or regulation.

• Balance plain-language readability with regulatory precision.

• Save hours you’d otherwise spend sorting out structure.

Want to see an example?
Here’s a ChatGPT session that creates and reviews a policy on the CY 2025 Outpatient Prospective Payment System requirement for written policies on transferring patients to an appropriate level of care: https://chatgpt.com/share/68bc41b2-64d4-8007-9658-05a29068ad06

⚠️Disclaimers and Cautions:

• Limited Source Data: The Health System Policy Assistant can help streamline policy drafting, but it does not replace official standards or regulatory review. It draws on ChatGPT’s general knowledge and publicly available information—not proprietary content from accrediting bodies such as the Joint Commission or DNV. This gap highlights an opportunity for policy management software vendors to integrate AI’s drafting and structuring strengths with licensed standards libraries, providing a more comprehensive solution.

• Hallucinations: Because AI may occasionally generate inaccurate or “hallucinated” content, confirm any unfamiliar references against authoritative sources.

• Human Review: For compliance, always reference your organization’s official standards and complete the normal Legal/Compliance review before final approval.

• No PHI or confidential information. Never upload patient data or sensitive internal content.

• Set privacy preferences. To prevent ChatGPT from using your uploads as training data, turn off Improve the model for everyone and set privacy to Do not train on my content.

What This Means for You

• For administrators: Hours saved every month, freeing you to focus on strategic priorities like stakeholder engagement and clinical judgment.

• For policy management vendors: A chance to deliver unmatched value by pairing AI with existing standards libraries and workflows.

• For healthcare leaders: Faster, more transparent, and more compliant policies that support better governance and safer patient care.

Ready to Try It?

Sarah doesn’t have to wrestle with research and structure alone anymore—and neither do you.

• Open the ChatGPT Health System Policy Assistant (free): Health System Policy Assistant.

• Try one of these prompts:

  • Find policies and standards related to <topic>. Here are some standards I am aware of: <list standards of interest>

  • Write a policy on <topic>. As the policy owner, the most critical items are mentioned in the draft policy: <Attach current policy>

  • Review my policy to see how it aligns with the standards identified on <topic> <Attach Policy>

  • Identify supporting documents for the attached policy. <Attach Policy>

• Want to write your own GTP? Contact me and I'll share the nearly 8000-character prompt used in the GPT.

• Explore more AI writing insights: AI Writing Blog List

The transformation of healthcare policy writing is already here. The only question is: will you be one of the first to take advantage?