Methodist Healthcare of San Antonio Enhances JCAHO Compliance
Methodist Healthcare System of San Antonio (MHS) is composed of seven hospitals with more than 6,000 employees including 2,000 physicians in 15 healthcare facilities around the San Antonio, Texas area. MHS sees more than 250,000 patients a year.
MHS utilized what they termed a “horrible” document management system that used primitive search methods, did not support uploading of documents and routinely lost or truncated documents within the system causing great difficulty during essential Joint Commission surveys.
It was no surprise then, when Joint Commission audits identified areas of weakness in MHS’s policy management system. Surveyors discovered that employees could not find documents in MHS’s electronic policy manager and some policies were not kept current. Additionally, policy documents were difficult to find and difficult to edit. While these shortcomings were not fatal to the JCAHO survey, they did alert MHS officials to the need for improved policy management.
To remedy the problem, MHS now operates NAVEX Global’s PolicyTech policy management software, making the process more reliable with automated policy tracking, readership quizzing and the multipurpose use of PPM documents. The software gave MHS a convenient way to store policies and procedures with a robust search engine, automated review and approval system, and the ability to infuse pictures, links and videos into the documents making it a multifunctional document storage tool.
Efficient Policy Management A Big Relief
MHS is the largest healthcare provider in the San Antonio, Texas area. As such, its policy and procedure management needs are significant.
“The old system needed an enormous amount of manipulation,” said Susan Andrews-Carden, RN, MS, MHS Director of Clinical Informatics. “It just wasn’t that friendly of a system. There wasn’t a way to refine the search. There was no guidance to the end user on how to help you find that search.”
Connecting People Through Policies
Besides being difficult to use, their former program lacked notification for policy review as well as a document archive. Furthermore, the system required users to have email accounts—something most staff do not have.
“It was a hot issue with the vice presidents, so I said ‘how do we (fix it)?’” Andrews-Carden said. When she came across NAVEX Global’s policy management software, with its exclusive endorsement from the American Hospital Association and robust search engine, she knew she was on to a solution to her document management problems.
“The number one reason we chose NAVEX Global was the depth of the search engine,” said Andrews-Carden. PolicyTech’s variety of search features includes keyword, title, in-text, author, date and process searches.
MHS was also enticed by the automated reminders for policy review. Next the ability to embed photos, links, videos and various file types into the system appealed to their desire to use the software to handle a broad variety of documents in addition to hospital policies and procedures.
Software Features Connect Hospital Staff
NAVEX Global’s wide array of policy-specific features made it an easy choice to implement at MHS’s multiple healthcare facilities. “Every (software) does some tracking features, but nobody does it as well as NAVEX Global,” said Andrews-Carden.
The prominent features allow document administrators to view documents in each step of the draft, review and approval process, as well as create reports of which readers have read—or have not read—each document. Reviewers use Microsoft Word™ reviewer tools to edit and make suggestions to documents all along the approval process.
While the software is compatible with Active Directory, it is not a requirement for the system to function. Much of the MHS staff – including nurses, technicians and housekeepers – did not have email accounts. These employees can still have policy management accounts, read policies and be held accountable for their policies without an email address.
AHA Endorsement a Big Plus
As Andrews-Carden looked for a solution to her policy management problems, she took confidence in the American Hospital Association’s (AHA) excusive endorsement of NAVEX Global’s policy management software.
“The biggest ‘ah-ha’ was the AHA endorsement,” Andrews-Carden said. “The fact that it was a complete document management system was the icing on the cake.”
MHS also liked NAVEX Global’s offer of concurrent licensing. This licensing plan is an affordable system of software licensing where MHS purchases licenses based on the number of simultaneous users of the software rather than the number to total users. Concurrent licensing allows MHS flexibility to grow the solution as it adds users and facilities to their healthcare network. It also is a cost-efficient way to manage policies when shift work is a dominant feature of a company’s employment structure.
Conclusion
MHS faces JCAHO audits of policies and procedures once every two years, yearly corporate compliance audits and a three-year review cycle for all documents. In this highly-regulated environment, each employee needs to stay current on all relevant policies and procedures in order for this aspect of compliance to be satisfied.
Andrews-Carden keeps referring back to the software’s unique functionality and focus on policy and procedure management when considering the possibilities with the software.
“I love this product. I just love it. I don’t know why more people don’t know about it,” Andrews Carden said. “It can revolutionize the industry.”
About NAVEX Global, Inc.
NAVEX Global is the worldwide leader in integrated risk and compliance management software and services. Our solutions help organizations manage risk, address complex regulatory requirements and foster an ethical, productive workplace culture.