It’s 2 am… do you know where your policies are?

1. It’s 2 am… do you know where your policies are?

2. Where we started • The “big” policy book • Department books • No books • Duplicate books • Conflicting books • Outdated books • Books full of useless junk

3. Attempted solutions • Tracking in Excel • Posting on the intranet/ Shared Drive • Policy committees • Copies to every department manager • Signature sheets for staff sign off • Posting on bulletin boards • Listing in the weekly newsletter

4. Goals • Up to date policies that are organized and readily available for staff • Policies that are evidence-based and easily referenced • Policies that are reviewed regularly by key stakeholders with a mechanism for tracking review and approval • An archival and retrieval system • A tracking mechanism for staff awareness with immediate notification

5. Administrative Rules of MT • 37.106.330 MINIMUM STANDARDS FOR ALL HEALTH CARE FACILITIES: WRITTEN POLICY AND PROCEDURE (1) A written policy and procedure for all services provided in a health care facility must be available to and followed by all personnel.

6. Medicare CoPs • Current (document review) • Compliant with state and local laws (C-0154) • Incorporate standards from nationally recognized professional organizations (C-0226) • Incorporate external alerts and/or recommendations from national associations and governmental agencies for review and facility policy and procedure revision consideration; staff awareness of policies (C-0277) • Produce source material (C-0330)

7. Medicare CoPs • Developed with the advice of a group of professional personnel that includes one or more MD/DO and one or more mid-level (C-0272) • MD/DO participates in developing, executing, and periodically reviewing the CAH’S written policies governing the services it furnishes (0258) • Mid-level involvement in policy development, execution, and periodic review (C-0263) • Pharmacy director is actively involved in those committees responsible for establishing medication-related policies and procedures (C-0276) • Patient care policies reviewed on an annual basis by the professional group (C-0280)

8. Medicare CoPs • Revisions or modifications in the medical staff bylaws, rules, and policies, have been approved by the medical staff and the governing body (C0241) • Evidence that the health care policies of the CAH are evaluated, reviewed and/or revised as part of the annual program evaluation (C-0334) • Method for orienting non-CAH staff to CAH policies and procedures (C-0294)

9. Technology solutions • Internet search for a software solution • Online demos • Several managers already using MCN as a resource (purchased subscriptions to department manuals)

10. Resources needed • $$$$$$ (approximately $10K annually for the software license) • Start Up Time – to gather current policies & eliminate trash, get all in electronic format, set manual structure, upload existing policies, market the tool to staff • Ongoing Human Capital – system administrator to upload new policies, manage users, train, set up and monitor approval processes, assign competencies, troubleshoot the software, run backups (up to 0.5 FTE)

11. Results • All goals achieved • Bonus: a library of over 30 manuals with sample policies plus Stay Alert subscription • Available from any computer with internet access • AND THERE’S MORE…

12. FORMS • Internal forms • Medical record forms • Patient education materials • One source for the most current version to print • A process for regular review • AND THEN WE HAD ANOTHER IDEA…

13. CONTRACTS • Had a good manual process for initial review • Difficulty maintaining an accurate database • Renewals a problem • Opportunity to train additional staff as administrators

14. Medicare CoPs • The CAH maintains a list of all services furnished under arrangements or agreements. The list describes the nature and scope of the services provided. (C-0291) • How does the CAH ensure, (e.g., through operating policies and procedures, by-laws etc.) that the individual responsible for its operations is responsible for all services provided through arrangements or agreements? (C-0292)

15. Medicare CoPs • The governing body must take actions through the CAH’S QA program to: assess the services furnished directly by CAH staff and those services provided under arrangement, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.(C-0285)

17. More results • Security/ access issues were addressed • Renewals not missed • Perpetual contracts not forgotten • One time contracts not left open indefinitely • BUT WE DIDN’T STOP THERE EITHER…

18. PAPERLESS MEETINGS • 20 page packets X (20 Department Managers + 5 Members Senior Leadership) X 12 meetings per year • 20-50 page packets X (5 Board members + 5 Leadership + 5 Others) X 12 meetings per year • Required investment into laptops

19. New Day, New Way

21. Leadership in Energy & Environmental Design bhh.ellucid.com • Customizable (BPM – Barrett Policy Manager) • 5 levels of organization forms-internal-medical staff-core privileges • Searchable (any word in the document + keywords, favorites, recent documents) froi • Reading assignments to staff with/without quizzes My competencies • Anyone in the organization can be assigned to give input on a document; tasks fecal leukocytes email reminders; history viewable Edit manuals: forms-med rec-pt care-transfer form (point out key words, form specifics review cycle, current editing, previous process notes) • Security settings by user and by manual • As users change roles, processes update automatically • Ability to back up to local server • Guest usage • Access to sample policies/ Stay Alert subscription policy library

22. POLICY & CONTRACT MANAGEMENT