Policy Management Case Study- Cedars-Sinai Health System’s Approach


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The typical organization faces a variety of problems when it comes to managing policies and procedures, including documents that are out of date, ineffective or not aligned to business needs. In this presentation, Mary MacGran of Cedars-Sinai Medical Center reveals how they tackled policy and procedure management challenges to enhance the delivery of health care services and improve employee satisfaction and performance.

This case study outlines Cedars-Sinai’s path to an effective and efficient policy and procedure management system. You will learn how they went from a cumbersome, decentralized system to a centrally controlled document management system within their newly created Policy Management Office.

Presented by:
Mary MacGran, Manager, Corporate Compliance, Cedars Sinai Medical Center
Monique Showalter, Director, American Hospital Association

Published in: Business, Technology
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Policy Management Case Study- Cedars-Sinai Health System’s Approach

  1. 1. CLIENT CONFERENCEMary MacGran – Monique ShowalterCase Study: Cedars-Sinai Health System’sApproach to Policy Management WorkflowCLIENT CONFERENCE
  2. 2. CLIENT CONFERENCEAgenda Welcome and Introductionso Monique Showalter, AHA Solutions Cedars-Sinai’s Approach to Policy Management Workflowo Mary MacGran, Corporate Compliance ManagerCedars-Sinai Medical Center Q&A Session
  3. 3. CLIENT CONFERENCEAbout AHA SolutionsAs a subsidiary of the American Hospital Association, AHA Solutions, Inc. isfocused on improving the operational performance of our nation’s hospitals.Through a broad variety of services, we provide hospitals with fieldleadership, education and research.Addressing critical staffing issuesby aligning 260+ tradeassociations to connect healthcare employers with highlyqualified candidatesResearching pressing operationalissues, conducting due diligence,and awardingthe AHA Endorsement
  4. 4. CLIENT CONFERENCEAbout This SessionNAVEX Global’s PolicyTech, (Policy & Procedure Management Software) hasearned the exclusive endorsement of the American Hospital Association.
  5. 5. CLIENT CONFERENCEWho are we?Why we needed a policymanagement system?What were the conditions beforethe adoption?Who – What - Why
  6. 6. CLIENT CONFERENCEWho We Are Cedars-Sinai Health System, Los Angeles, CAo 977-bed community medical centero Academic centero Research instituteo Managed care network 2:3 ratio of documents to employees!
  7. 7. CLIENT CONFERENCEWhy We Needed a Policy Management System Our patients! Staff need documents that are:o Current, Reliable, Accessible Management needs:o Compliance assessment toolso Comprehension measurement tools
  8. 8. CLIENT CONFERENCEBefore the Plunge An estimate of 10K document Decentralized document management Difficulty measuring comprehension Reactive quality assessment
  9. 9. CLIENT CONFERENCEOfficial and “Unofficial” Sites for Documents
  10. 10. CLIENT CONFERENCEBefore…… Reminders not automatic or persistent “Orphaned” documents Document cloning Delayed posting to Intranet page Manual management tools
  11. 11. Confusion about Documents!!
  12. 12. CLIENT CONFERENCEThe selection teamTeam responsibilitiesDefining the systemEstablishing controlThe Team and Their Roles
  13. 13. CLIENT CONFERENCEThe Selection Team VP Corporate Compliance VPs and Senior VPs Project Manager Enterprise Information Systemso For the technical know-how
  14. 14. CLIENT CONFERENCESelection Team Responsibilities Identify criteria for selection Review vendor proposals Select vendor Create a “policy on policies” Establish implementation timeline Monitor progress
  15. 15. CLIENT CONFERENCEDefining the “Ideal System” Centrally managed, single system Document search features Automated Workflow and Notificationso Built-in tickler system using emailo Instant publication of documentso Auto archiving and version controls Comprehension and compliance measures
  16. 16. CLIENT CONFERENCEEstablishing Central Control Policy Management Office (PMO), a Division of CorporateComplianceo Central control of operationso Policy and Procedure Guidanceo Document conversiono Training & Help Desko Monitoring & Reporting
  17. 17. CLIENT CONFERENCEPlanningPreparatory materialsDefining the needKey decisionsTimeline and resourcesPlanning and Implementation
  18. 18. CLIENT CONFERENCEPlanning the Implementation Team leads from each functional area were appointed by VPsand Senior VPso To work with the Policy Management Officeo Define departmental parameters and nuanceso Act as communication liaison during and after conversion
  19. 19. CLIENT CONFERENCEOccasionally, a condition called “Chronic Team Leader Fatigue Syndrome”was detected.
  20. 20. CLIENT CONFERENCEPreparatory Materials “Policy on Policies” Basic Templateso Policy, Procedure, Form, Work Paper Recommended hierarchical structure Conversion Workflowo Step-by-Step process from gathering documents throughpublication
  21. 21. CLIENT CONFERENCEPlanning the Implementation Strategic Planning Retreato 50+ Team Leaderso 2-day off-site retreato Participation from Policy Technologies• Demo software• Answer questionso Request anonymous input• Audience response system
  22. 22. CLIENT CONFERENCE 22For the most part, CSMC policies and procedures arepoorly available (hard to find)…28%56%8% 8%0% Strongly agree. Agree. Neither agree nor disagree. Disagree. Strongly disagree.
  23. 23. CLIENT CONFERENCE 23The current manner in which we handle policies andprocedures is working...0%7%37%44%12% Very well. Well. Neither well nor poorly. Poorly. Very poorly.
  24. 24. CLIENT CONFERENCEKey Decisions Functional categorization of documentso Administration, Finance, Human Resources, Academic Affairs, ClinicalCare, Medical Delivery Network 2-Phase Conversion Voluntary Sign-up for Phase I One size doesn’t fit all - we would work with individual teams. The Policy Management Office mantra:“Maximize support, minimize stress, develop rapport”
  25. 25. CLIENT CONFERENCEImplementation Timeline/Resources Document Conversiono Phase I - 6 monthso Phase II – 12 monthso Resources Neededo Information Technology0.5 FTE 4-6 monthso Manager, Policy Management Office0.8 FTE, 12 monthso Temporary Staff2-3 FTE’s, 12-15 months
  26. 26. CLIENT CONFERENCEBefore and afterDocuments by typeUser feedbackThe Results
  27. 27. CLIENT CONFERENCEBEFORE REQUIREMENT/GAP AFTERIntranet web site, shareddrives, personal desktops,paper manuals, etc.Central Repository99% of all documentsreside in PPM Late posting of documentson Intranet page Version control inconsistent Archival processesinconsistent/non-existentVersion Control Documents publish toPPM as soon as theyare approved Auto archival ofprevious versionN/A Automation ofWorkflowEmail notification systemManual process ComplianceAssessment Tools AutomatedManagement Reportsusing system data
  28. 28. BEFORE REQUIREMENT/GAP AFTERVarious formats fornotification E-mail Department meeting Word of mouth Phone callsNotify/Track RequiredReaders Notify Required Readersvia email as soon as adocument is publishedand/or approved andtrack requirementDecentralized control atdepartmental/local levelCentral Control  Policy ManagementOffice10,000+ documents Reduce Number ofDocuments8,500UnstructuredmanagementDevelop DocumentManagement TeamsDesignated DepartmentalTeam LeadersDuplicate documents;inconsistency betweendepartmentAlign ClinicalDocumentsOne Clinical Manual
  29. 29. CLIENT CONFERENCEAcademic Affairs411Administration1437Clinical Care5876Financial Services551Human Resources76Medical DeliveryNetwork372Documents by Main CategoriesAcademic AffairsAdministrationClinical CareFinancial ServicesHuman ResourcesMedical Delivery Network
  30. 30. CLIENT CONFERENCEUser Feedback “We went from 400 documents to just 100 during our conversion to PPM!We took a critical look at our policies and procedures and eliminated lots ofunnecessary or duplicative documents” - Manager Rehabilitation andNeuropsychology Documents are accessible – “I know where to go!” There is no doubt when a document is due for review (Sometimes that’s acomplaint!) Required Readers instantly notified of new versions – a plus fordepartments with limited time for meetings Management tools and reports inspire compliance with “TJC was so impressed when we just pulled up the documenton-the-spot”. “Thank goodness we finally did it!”
  31. 31. CLIENT CONFERENCEContacts:mshowalter@aha.orgmacgranm@cshs.orgQ&A