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Web-based solution helps hospital keep up with regs: managers at a 25-bed critical-access hospital hoped the software could make regulatory surveys smoother by addressing their three biggest challenges.

Accreditation bodies, such as the Joint Commission and Centers for Medicare and Medicaid Services (CMS), stress the importance of following policies and procedures for providing safe, quality patient care. These bodies conduct frequent regulatory surveys to ensure hospitals fall in line with their own standards as well as those required to achieve national patient-safety goals.

To keep up with pertinent standards and regulations--but most importantly, to provide the best possible care for the patient--St. Vincent Randolph, A 25-bed acute-care facility serving the residents of Randolph County, Ind., chose to implement PolicyStat's web-based policy and procedure-management software in early 2011. Managers at the 25bed critical-access hospital hoped the software could make regulatory surveys smoother by addressing their three biggest challenges:

1. Making policies more easily accessible to staff by putting a centralized, easily searchable repository in place to organize and store policies;

2. Increasing accountability by ensuring associates refer to policies and by holding policy authors accountable for editing and updating policies within the appropriate timeframe; and

3. Standardizing policies throughout not only the hospital, but also with other hospitals across the St. Vincent Health system.

Director of Human Resources Zach Matthews and Chief Nursing Officer Carla Fouse were charged with getting policies and procedures up and running in the PolicyStat system. "When PolicyStat came to present theft product, I knew their system was going to be an immense improvement over our current paper system," Matthews says.


Shortly after a recent Joint Commission survey at St. Vincent Randolph, CMS conducted an extensive validation survey. Normally, CMS comes in with an itinerary and conducts a "tracer," where they take a certain population, age group or diagnosis and pull a chart on the nursing unit, for example. They check that standards are being followed--especially in regard to national patient safety goals--then ask associates questions about specific policies related to those standards or goals. Each survey ends with an exit interview conducted by the auditors, with results ranging from simple fixes to significant issues for which an action plan must be implemented.

Surveyors look for different things, but mainly they want to make sure staff knows where each policy is. "It would be very unsafe to the patient if we had associates providing treatment without the ability to consult policies," Fouse says. "Our goal is to provide safe patient care and to create a culture that promotes safety in all situations."

Challenge #1 : Make policies easily accessible

Joint Commission and CMS surveyors ask how associates know about a policy and where they can access it. "We lacked a system that would effectively inform all staff at once about new or revised policies," Matthews says. Before PolicyStat, managers just made sure to inform associates of new or revised policies at the departmental meetings. Managers would still need to print policies off and hand them to associates.

The PolicyStat system made it easy for associates to find and access any policy in any area with a simple, Google-like search function. "With PolicyStat, nursing staff can easily find and access all applicable policies--not just those specific to his or her area, but also those in any of the other nursing units," Fouse says.

Before PolicyStat, St. Vincent Randolph also lacked an organized way of housing policies, making it difficult to find policies on the spot during a survey. "The surveyors usually gave me a list of policies ahead of time which I could then pass off to the appropriate managers to retrieve," Fouse says. During the most recent survey, however, auditors asked for policies to be produced right there on the spot. "PolicyStat allowed us to access the requested policies on demand," Fouse says. After the most recent survey, managers who had not yet started using PolicyStat saw how it could help them access policies faster and make surveys go smoother. They immediately started jumping on board and importing their policies.

Challenge #2: Increase accountability

Surveyors want to see an organized and formal policy process for managing policies and communicating them to associates, and they also expect associates to know where to go to find the information they need. To address both concerns, St. Vincent Randolph put a system in place for increasing accountability.

While some hospitals used an intranet database to store and manage their policies and procedures, St. Vincent Randolph was using a completely paper-based system. The paper-based system often led to confusion regarding who was responsible for what policies and when they needed to be updated.

With the PolicyStat system, authors are held more accountable for editing and updating policies within the appropriate timeframe, so that all policies are kept active and applicable at all times. "We've seen a night-and-day difference with PolicyStat versus our outdated paper-based policy system," Matthews says. "PolicyStat gives us a more organized system with better accountability."

PolicyStat has greatly improved accountability among all associates, not just management staff. Each associate is now able to find policies and print them off within minutes, versus spending more time hunting to find which policies are applicable and active. "There is more transparency for the associates," Matthews says. "PolicyStat has helped us get all policies in one place, and staff can access policies whenever they want. This is a much-improved process for us."

Challenge #3: Standardize across the hospital and across the system

Before PolicyStat, inconsistencies existed among policies with similar procedures. It was crucial that these inconsistencies were resolved--especially before a survey--but it was a tedious process. "We didn't have an effective way of keeping policies updated," Fouse says. "All policies had to be updated at the same time, and that was a huge undertaking for surgery and reed surg units that had hundreds of policies."

It was also vital for St. Vincent Randolph to standardize using the most current, evidence-based policies and procedures. Time Out, for example, is a requirement on the forefront of many procedures, but it was not outlined the same in all policies. "We had Time Out in the procedures for surgery but not in the med-surg unit," Fouse says. "When we perform a procedure in med surg, we should be doing it the same way as in the ER and OR." PolicyStat's software and the organized implementation process made standardizing policies achievable and less overwhelming, helping St. Vincent Randolph to reduce these types of inconsistencies.

Using PolicyStat's applicability feature, authors at St. Vincent Randolph are now able to share and standardize policies across the St. Vincent Health system, borrow policies from other ministries and make them their own. This allows the entire health system to standardize across ministries and use only those procedures which are based on the most current, evidence-based practices.

"Policy writing can be a difficult process," Fouse says. "One of the best things I have found about PolicyStat is the ability to share policies across the system. I can go to their site and 'borrow' some of their best practices. I have to customize some of the policy to make it specific to our hospital, but the scientific process or general principle is there for me to use. It saves us time and effort to have something that already exists out there--we don't have to re-type or start from scratch."

"We've seen policies from other ministries that we hadn't yet thought of creating, but now we have been able to add them to our system too," adds Matthews. Sharing across ministries has allowed authors to standardize and share their evidence-based practices with authors in other ministries, ultimately leading to better quality of care for the patient.

Beyond surveys: Reducing risk and achieving organizational goals

Outside of normal standards and regulations, St. Vincent Randolph also takes a proactive approach on their own to reduce risk and improve care for the patient. "We conduct a risk assessment every year by a body called the Nursing Senate," Fouse says. The Nursing Senate is part of St. Vincent Randolph and includes elected members from each unit. It gives front-line staff shared governance and a say in how nursing provides patient care.

One of the goals for this year's Nursing Senate is to ensure associates know where to go for policies and to encourage the consistent use of PolicyStat. To help reach this goal, members from the Nursing Senate help staff access PolicyStat and show them how to use it. They encourage associates to go to PolicyStat and look something up if they are unsure. "It makes me feel good that they saw this as an issue and decided to work on it," Fouse says. "Following policies and procedures is vital to providing safe, quality patient care. And that's what's most important."

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Title Annotation:Regulatory Issues
Publication:Health Management Technology
Date:Jan 1, 2012
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