Crossing the quality chasm

Automated policies are safer than manual policies.

Instinctively, many healthcare professionals would not debate this fact, but how many of them really understand the foundations that make this a true statement?

In 2001, the Institute of Medicine (IOM) report “Crossing the Quality Chasm – A New Health System for the 21^st Century”, recommended six “aims for improvement” as part of the redesign of the American health care system. The intent being to set forth a specific direction for policymakers, healthcare leaders, clinicians, regulators, purchasers and others to improve healthcare..  These six aims are safety, effectiveness, patient-centeredness, timeliness, efficiency and equity.

Is your organization seriously evaluating its current process and practices as it relates to policy and procedure management to ensure it aligns with these aims? To figure out if your system meets or beats the standards for the American health care system, let’s consider the IOM’s six aims as it pertains to policy management.

Aim #1: Healthcare must be safe.

Healthcare professionals understand the concept “first do no harm” and that it is their responsibility to be more careful and aware of those human factors that can contribute to making errors.  Performing risk assessments, talking about failure points (FMECA), piloting changes before spreading initiatives house-wide are all actions that healthcare professionals – most of all quality assurance professionals – need to make a priority. As leaders in healthcare, we need to be proactive, constantly checking progress and evaluating outcomes: what is commonly known as the cycle for improvement, or the plan-do-check-act (PDCA) problem solving process.

How do you know if your policy management process is safe? Simple: perform a tracer activity, one of the activities the Joint Commission performs during survey spot checks. This consists of following a process or a patient encounter from beginning to end, observing, asking questions of staff and looking in the charts as needed to determine compliance with standards. You may be taken by surprise that there are blatant unsafe practices taking place in your healthcare facility.

Aim #2: Healthcare needs to focus on being effective.

It explains that healthcare should match science and not overuse or underuse available best techniques. Look at policy management as the service being delivered. What we put in a policy affects the outcome. We can analyze the process for effectiveness.  For example, if an employee follows an outdated clinical pathway, the old procedure will not be as effective as the one that reflects current practice.

Aim #3: We need to look at policy management as being “patient centered”.

This aim is particularly relevant since policies guide how the care is delivered to the patient. Our system needs to fix the gaps that are roadblocks to patient centricity. Having access to the most current policy is imperative to ensuring that staff follow an informed consent process, and simultaneously ensures that the patient is adequately involved in making decisions about their own treatment plan. This is not only patient centric, but also a CMS and Joint Commission requirement. During a survey, I witnessed a healthcare facility that was in an absolute mess regarding informed consent. Surveyors requested a copy of the informed consent policy from three different managers and they received three different copies.  This incident was an eye-opener that forced management to look into updating their policy management structure. They asked for the policy on policies, which they did not have. Thus, they had to develop an immediate action plan to innovate their policy management.  One of their most successful implementations was to have their policies online, and have only the most current version posted for the staff to see and comply to.

Aim #4: The care we provide should be timely.

How much time is wasted trying to find the manual and the policy we need?  How much time is spent routing a paper policy through the system to get approval and feedback from all those it implicates?  Then we find out that the one disseminated doesn’t include all the input and that the wrong version was given to staff. When we have to send an alert to staff rescinding the last version, we create feelings of mistrust toward the process and lack of confidence in the quality of information.

What if an employee needed to refer to a procedural policy immediately for the patient’s procedure? The time spent finding it means a delay in treatment – which is unsafe for the patient. In addition, having the nurse waste his/her time looking for a policy means taking more time away from the bedside and adds to staff dissatisfaction.

Aim #5: Healthcare should be efficient.

Hospitals know now, more than ever, that we need to reduce waste and cost. Manual policy management is inefficient in the sense that it eats up a hospital’s time, financial and human resources, all of which should be devoted to direct patient care.

Aim #6:  Healthcare should be equitable.

Employees should be able to work on any unit in the hospital and have the same access to the policies that they need to do their job. There should be consistent mechanisms to inform staff of new policies and/or changes in current policies that are relevant to them.  New employees need a channel during orientation through which they can learn about this mechanism and it should be listed on their competency checklist. In addition, the policy process should be standardized and hardwired so that, at any point in time, the correct procedure is provided to a surveyor or attorney upon request.  Patients should be able to come to any hospital and receive the same evidence-based care.  That is dependent on the policies, procedures and other documents caregivers rely on to deliver their care.

In light of this, where are we headed?

Automation with medication records (EMRs) and computerized physician order entry (CPOE) are the way of the future for healthcare organizations.  Likewise, document management systems for policies will benefit your organization in minimizing the work and effort needed to align a manual system with the six aims, in providing automatic and electronic mechanisms in store to assist the staff.

If you are targeting a safe, successful policy management system, it will only happen if you align your process with the six aims of healthcare safety; by becoming automated, you are well on your way to hitting your mark!

Nicola Heslip | Certified Professional in Healthcare Quality | PolicyMedical

For the full article, check out the upcoming edition of New Perspectives, published by the Association of Healthcare Internal Auditors

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