Policy and Procedure Management for Healthcare

Copyrights HospitalPortal.net 2015. All rights reserved.
Policy and Procedure
Management for Healthcare
Presented by:
Albert Jurkiewicz; Policy & Procedure Manager Developer
Jason 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

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 right
things, 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 - Preparation
Step 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 Roles
Configuration
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.

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 & A
JKOshita@HospitalPortal.net
Marketing@HospitalPortal.net
CustomerService@HospitalPortal.net

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