policy and procedure management for healthcare

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Policy and Procedure Management for Healthcare

Presented by:Albert Jurkiewicz; Policy & Procedure Manager DeveloperJason Oshita; Manager of Client Services


About HospitalPortal.net Out-of-the-box Intranet and Policy and Procedure

Management System

Used by over 170 Hospitals and Clinics across the U.S.

Training and Implementation Support


Agenda Policy Automation in healthcare

Anxieties and fears

Planning, executing, and organizing your implementation process• Step By Step Approach

Best practices for system implementation & pre-implementation

What can make or break your P&P process

Examples to support our discussion

Q&A


What is Automated Policy Management Software?

Policy Manager

Search &Access Reviews

and Revisions

Reporting

Notification

Audit Trail


Moving towards an Automated P&P System

Pre-Implementation, selection, & project inception

Implementation

Post Go-Live


Pre-Implementation: Identify your objectives

How do you manage your P&Ps right now?

Why are you looking to improve your P&P System?

What doesn’t work & what works?


POLL QUESTION


Pre-Implementation: Identify your objectives

How do you manage your P&Ps right now?

Why are you looking to improve your P&P System?

What doesn’t work & what works?


What doesn’t work…?

Multiple policy repositories. Staff doesn’t know where to go for current policies.

Impossible to search and find policies


What does/need to work…?

Searchable

Easy to use

Transparent

Flexible


Getting from where you are to where you want to be!

Provide a structure for the process

Workload

Time it takes to get the policies implemented


Providing Structure to the Process

Get the right people, in the right roles, doing the rightthings, at the right time

Responsibilities

Workflows

Electronic Platform

Make it difficult to make mistakes


Workload…

Heavy : (

Align resources, leadership, and tools…


Aligning Resources, Leadership, & Tools

Project Manager

Strong Leadership Support

Department Heads

Vendor Assistance


Timeframe of Policy Implementation

Questions to ask yourself… Are your policies in electronic format?

Approval requirements identified?

Are your policies in the most updated templates?

Are there any duplicates that need to consolidated? How many?

Do the policies need to be changed/approved before they get uploaded?

Any other projects that could take up or are taking up company resources?


Implementation Process - PreparationStep 1: Organize policies and procedures

Step 2: Document clean-up

Step 3: Develop structure and organization

Step 4: Determine responsibilities

Step 5: Establish review dates

Step 6: Prepare for upload

Step 7: Upload

Step 8: Go Live


Step 1: Organize policies and procedures

Identify documents• Those that are there

• Those that can’t be found

Identify duplicates

Tame the Chaos!


Step 2: Document Clean-Up

Make sure the correct templates are in place.• Update as needed.

Identify review and revision dates.

Come up with a naming convention.


Step 3: Develop a structure for policies How will staff search/browse for policies?

Are there any standards you need to follow?

Break down by department or type• Clinical vs. Non-Clinical• Departmental vs. Organization-wide• Other organizational methods

Address access to shared policies.• Cross-linked rather than duplicated – if possible

Linkage between Policies, Procedures, and Forms.• Do they need to be visually linked for end users?


Step 4: Map the Process and Assign RolesConfiguration

and

Organization

Policy Authoring

and

Revisions

Expert Reviews

and

Approvals

Read Acknowledgement

Tracking

Publishing

Of

Finalized and Approved

Revisions

Periodic Reviews

And Revisions

Archiving

Old Policies

Moderators /Administrators

Reviewers /Approvers

Authors /Writers

Staff /End Users


Step 5: Effective and Next Review Dates

Identify effective dates.

Identify and next review dates.

Be realistic given the approval workflow. • Very aggressive review dates may lead to unmanageable

backload when system goes live!


Step 6: Prepare for upload

Organize policies into folders

Policy and Procedure worksheets File name Designated Location Title (display name) Effective date Next review date Next reminder date Responsibilities


Step 7: Upload

Need to have everyone’s policies ready

Coordinate with Go-Live date

Coordinate along with training sessions


Training Sessions Preview session(s) Share understanding of objectives and “end result”

Gets everyone on board

Moderator/system administrator-specific session

Approver & authors training Focusing on applicable features and functions only

Post-implementation/refresher Training


End Users

Should not need training

Need to have trust in the system Search-ability

Completeness

Easy and logical browse access


Step 8: Go Live

GO LIVE!!!


Phased Policy Implementation Option

Going live with older versions of policies is OK, but…• The policy library should be as complete as possible even if it

contains policies that still need to be reviewed.

• Must be prepared to update “temporary” policies in a reasonable amount of time.

• Use system to manage revisions of “temporary” policies and set achievable review dates.


Managing Other Documents…

Forms

Standing Orders

Employee Onboarding Documents

Case Management and Patient Education

Read & Sign

Clinical Standard Work

Staff Training Materials

Contracts


Example of a Policy and Procedure Manager


Don’t fall back into your old ways! On screen alerts

Email notifications and summary emails

Reports

Audit trail/accountability

Self-managed process of approval routing

Review & revision reminders

Read acknowledgements

This will make everyone’s lives easier!


Q & [email protected]@[email protected]

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