Policy Management Case Study- Cedars-Sinai Health System’s Approach
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CLIENT CONFERENCE Mary MacGran – Monique Showalter Case Study: Cedars-Sinai Health System’s Approach to Policy Management Workflow CLIENT CONFERENCE
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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faces a variety of problems when it comes to managing policies and procedures, including documents that are out of date, ineffective or not aligned to business needs.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
Transcript of Policy Management Case Study- Cedars-Sinai Health System’s Approach
CLIENT CONFERENCE
Mary MacGran – Monique Showalter
Case Study: Cedars-Sinai Health System’s Approach to Policy Management Workflow
CLIENT CONFERENCE
CLIENT CONFERENCE
Agenda
Welcome and Introductions
o Monique Showalter, AHA Solutions
Cedars-Sinai’s Approach to Policy Management Workflow
o Mary MacGran, Corporate Compliance Manager
Cedars-Sinai Medical Center
Q&A Session
CLIENT CONFERENCE
About AHA Solutions
As a subsidiary of the American Hospital Association, AHA Solutions, Inc. is
focused on improving the operational performance of our nation’s hospitals.
Through a broad variety of services, we provide hospitals with field
leadership, education and research.
Addressing critical staffing issues by aligning 260+ trade
associations to connect health care employers with highly
qualified candidates
Researching pressing operational issues, conducting due diligence,
and awarding the AHA Endorsement
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About This Session
NAVEX Global’s PolicyTech, (Policy & Procedure Management Software) has
earned the exclusive endorsement of the American Hospital Association.
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Who are we?
Why we needed a policy management system?
What were the conditions before the adoption?
Who – What - Why
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Who We Are
Cedars-Sinai Health System, Los Angeles, CA
o 977-bed community medical center
o Academic center
o Research institute
o Managed care network
2:3 ratio of documents to employees!
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Why We Needed a Policy Management System
Our patients!
Staff need documents that are:
o Current, Reliable, Accessible
Management needs:
o Compliance assessment tools
o Comprehension measurement tools
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Before the Plunge
An estimate of 10K document
Decentralized document management
Difficulty measuring comprehension
Reactive quality assessment
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Official and “Unofficial” Sites for Documents
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Before……
Reminders not automatic or persistent
“Orphaned” documents
Document cloning
Delayed posting to Intranet page
Manual management tools
Confusion about Documents!!
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The selection team
Team responsibilities
Defining the system
Establishing control
The Team and Their Roles
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The Selection Team
VP Corporate Compliance
VPs and Senior VPs
Project Manager
Enterprise Information Systems
o For the technical know-how
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Selection Team Responsibilities
Identify criteria for selection
Review vendor proposals
Select vendor
Create a “policy on policies”
Establish implementation timeline
Monitor progress
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Defining the “Ideal System”
Centrally managed, single system
Document search features
Automated Workflow and Notifications
oBuilt-in tickler system using email
o Instant publication of documents
oAuto archiving and version controls
Comprehension and compliance measures
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Establishing Central Control
Policy Management Office (PMO), a Division of Corporate
Compliance
o Central control of operations
o Policy and Procedure Guidance
oDocument conversion
o Training & Help Desk
oMonitoring & Reporting
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Planning
Preparatory materials
Defining the need
Key decisions
Timeline and resources
Planning and Implementation
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Planning the Implementation
Team leads from each functional area were appointed by VPs
and Senior VPs
o To work with the Policy Management Office
oDefine departmental parameters and nuances
oAct as communication liaison during and after conversion
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Occasionally, a condition called “Chronic Team Leader Fatigue Syndrome” was detected.
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Preparatory Materials
“Policy on Policies”
Basic Templates
o Policy, Procedure, Form, Work Paper
Recommended hierarchical structure
Conversion Workflow
o Step-by-Step process from gathering documents through
publication
CLIENT CONFERENCE
Planning the Implementation
Strategic Planning Retreat
o 50+ Team Leaders
o 2-day off-site retreat
o Participation from Policy Technologies
• Demo software
• Answer questions
oRequest anonymous input
• Audience response system
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For the most part, CSMC policies and procedures are poorly available (hard to find)…
28%
56%
8% 8%
0%
Strongly agree.
Agree.
Neither agree nor disagree.
Disagree.
Strongly disagree.
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The current manner in which we handle policies and procedures is working...
0%
7%
37%
44%
12%
Very well.
Well.
Neither well nor poorly.
Poorly.
Very poorly.
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Key Decisions
Functional categorization of documents
o Administration, Finance, Human Resources, Academic Affairs, Clinical Care, 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”
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Implementation Timeline/Resources
Document Conversion
o Phase I - 6 months
o Phase II – 12 months
o Resources Needed
o Information Technology
0.5 FTE 4-6 months
o Manager, Policy Management Office
0.8 FTE, 12 months
o Temporary Staff
2-3 FTE’s, 12-15 months
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Before and after
Documents by type
User feedback
The Results
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BEFORE REQUIREMENT/GAP AFTER Intranet web site, shared
drives, personal desktops,
paper manuals, etc. Central Repository
99% of all documents
reside in PPM
Late posting of documents
on Intranet page
Version control inconsistent
Archival processes
inconsistent/non-existent
Version Control
Documents publish to
PPM as soon as they
are approved
Auto archival of
previous version
N/A Automation of
Workflow
Email notification system
Manual process Compliance
Assessment Tools
Automated
Management Reports
using system data
BEFORE REQUIREMENT/GAP AFTER Various formats for
notification
Department meeting
Word of mouth
Phone calls
Notify/Track Required
Readers
Notify Required Readers
via email as soon as a
document is published
and/or approved and
track requirement
Decentralized control at
departmental/local level Central Control
Policy Management
Office
10,000+ documents Reduce Number of
Documents
8,500
Unstructured
management Develop Document
Management Teams
Designated Departmental
Team Leaders
Duplicate documents;
inconsistency between
department
Align Clinical
Documents
One Clinical Manual
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Academic Affairs 411
Administration 1437
Clinical Care 5876
Financial Services 551
Human Resources 76
Medical Delivery Network
372
Documents by Main Categories
Academic Affairs
Administration
Clinical Care
Financial Services
Human Resources
Medical Delivery Network
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User 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 of unnecessary or duplicative documents” - Manager Rehabilitation and Neuropsychology
Documents are accessible – “I know where to go!”
There is no doubt when a document is due for review (Sometimes that’s a complaint!)
Required Readers instantly notified of new versions – a plus for departments with limited time for meetings
Management tools and reports inspire compliance with
“TJC was so impressed when we just pulled up the document on-the-spot”.
“Thank goodness we finally did it!”
