Cedars-Sinai Health Systems
Cedars-Sinai is known for providing the highest quality patient care. Their dedication to excellence, compassion and innovation is rooted in the Judaic tradition and its devotion to the art and science of healing, which informs every aspect of their four- fold mission:
- Leadership and excellence in delivering quality healthcare services
- Expanding the horizons of medical knowledge through biomedical research
- Educating and training physicians and other healthcare professionals
- Striving to improve the health status of our community
Why Policy Management?
In healthcare organizations large and small, policies and procedures are a critical part of the foundation for success.
They must be current, accessible and reliable to users because they contain the key procedures and processes that produce excellence. Ask any compliance professional and you will learn that an outdated, inaccessible, or poorly communicated policy or procedure is often the main factor in a quality or compliance issue. For this reason alone, every organization should assess their policy management activities and consider options to automate the process.
This study looks at Cedars-Sinai Health System’s (CSHS) path to an effective and efficient policy and procedure management system. It will review their document management challenges before installing NAVEX Global’s PolicyTech® as well as the internal processes that made way for the positive changes and quality results.
Step One: Gap Analysis
Like many other healthcare organizations, Cedars-Sinai recognized that their hybrid approach to policy management needed an overhaul. As the organization grew and expanded services so did the number of policies and procedures compounded by the increasing complexity of document management. There were an estimated 10,000 documents that were authored, reviewed, approved and published as part of the conversion to PolicyTech.
- Cedars-Sinai had an intranet site for policies and procedures, but shared drives, paper manuals and personal desktops were also used to varying degrees.
- Document management was controlled at the department level. This resulted in variation in quality, timeliness of review and sometimes even resulted in the creation of multiple documents for the same process.
- There was no simple, uniform method to confirm that affected staff read and comprehended critical policies and procedures. To hold someone accountable for performing a procedure or following a policy, one must first ensure that it has been communicated and understood.
- Management’s ability to assess compliance with all aspects of document management was largely a manual process, and most assessments were reactive when they occurred.
- An onerous alphanumeric system had been developed to categorize documents but often failed to deliver the intended benefit.
One too many times, a glitch in the document management process had an impact on the CSHS mission to provide the highest quality patient care services. In 2008, the vice president of corporate compliance answered the call for action. In spite of the ongoing implementation of a system-wide electronic medical records management system, the project was given top priority status by leadership.
“We went from 400+ documents to just 100 during our conversion to PolicyTech. We took a critical look at our policies and procedures, and eliminated lot of unnecessary or duplicated documents.”
- Pamela Roberts, Ph.d. Manager Rehabilitation and Neuropsychology, Cedars-Sinai Health System
Step Two: Creating the Wish List
It was agreed that both the implementation and ongoing management of a new system would become an added function within the department of Corporate Compliance. In concert with information technology services, the request for proposals (‘the wish list’) was developed and refined. It consisted of all the features lacking in the current hybrid model including the following:
Centralized control over the management of documents and the publishing process
One system and method to manage all critical documents
Automated versioning and document numbering
Quick and easy access to the documents for all staff members
Easy process for collaboration between key experts in the authorship phase
Immediate publication of newly approved documents with automatic archiving of legacy files
Automated notification to users with reading, reviewing and approval responsibilities
System resources and reporting options so management could quickly and completely assess compliance with review and approval requirements
Additional reporting options allowing management to quickly and completely assess both the policy review/approval process, and end-user comprehension
After reviewing several products, the selection committee agreed unanimously on NAVEX Global’s policy and procedure management software PolicyTech™. The team’s decision was further reinforced when they became aware that the American Hospital Association (AHA) Solutions, whose mission is “to foster operational excellence in hospitals,” also gave its exclusive endorsement to NAVEX Global’s PolicyTech.
Where is Cedars-Sinai Now?
- Currently about 8,000 documents, or 97%, of all policies, procedures, forms and job aids reside in PolicyTech
- The Policy Management office consists of a manager and a management assistant, with technical support provided by their enterprise Information Services department.
- Technical support requires less than 5 hours per week, with management spending 60-80% of their time involved in policy management activities.
- Resources include a web page, help desk, twice monthly 2-hour classroom training and an optional PolicyTech User’s Group forum once a month.
- Classes in technical writing and are currently planned for document authors.
Benefits of PolicyTech Implementation:
- No more delays or confusion when publishing new or updated documents; they are automatically published as soon as they are approved and effective.
- Managers are able to monitor read rate and test comprehension.
- Auditors and inspectors note the ease with which documents can now be accessed.
- Interdepartmental communication regarding policies and procedures has improved significantly and many duplicative documents and processes have been removed.
- Departmental web pages containing references to the policy documents are automatically routed to the most current version; no need to manually update the UrL.
- Built-in reminders and notifications via email have proven to be valuable techniques for keeping reviews on track.
- New subject matter experts and contributors are easily added to the system and are notified automatically as revisions or updates are needed on the documents that have been assigned to them.
- Reports that query the database provide the data for monitoring and process improvement.
- Departmental team leaders continue to provide significant assistance in their roles as liaisons to the Policy Management office.
About NAVEX Global, Inc.
NAVEX Global’s comprehensive suite of ethics and compliance software, content and services helps organizations protect their people, reputation and bottom line. Trusted by 95 of the FORTUNE 100 and more than 12,500 clients, our solutions are informed by the largest ethics and compliance community in the world.