Assessing the gaps of Your policy management system

Start Assessing Your Organization

How do you become well-equipped to navigate through the difficult process of assessing your organization for gaps in policy management?

I would start with creating a checklist as a tool to help you remember all the key points in the process. A complete assessment is necessary to ensure you don’t miss any vital information that would affect rolling out a new policy management system.

Creating the Checklists

I recommend making a checklist with questions to test staff’s knowledge of the policy management system, and then a checklist for on-site demonstrations of how they use and handle their policies. These two sets of checklists should be administered to two groups:

1. First, the front line staff that accesses the policies to deliver patient care.

2. Then, the ancillary staff that likely has their department-specific policies (for example, environmental services or pharmacy).

The checklists that you create will serve as guidelines for taking a holistic approach in assessing whether your hospital’s policy management system has any gaps. All of these questions require you to interact directly with staff who actually use the policies. Some of these require you to be on-site, while others do not.

Checklist #1: How Well Do You Know Your Policy Management System?

1. Do they know where to find organization-wide policies?

2. Do they know where to find their department-specific policies?

3. How often do they access the policies?

4. How much time do they spend looking for the policies?

5. For the C-suite: ask the chief nursing officer about the approval of nursing policies and how that takes place. Is there a policy on policies? Does the CNO attend the policy committee meetings to ensure the process is being followed? Have they performed a cost-benefit analysis to determine how much time and money they spend managing policies they way they do?

For example, just having 10 staff at a 4 hour policy committee meeting ($40/hr x 4 hrs = $160, x 10 staff members) is $1600. Some organizations have all day meetings and the hourly wage can be more for senior leadership. And make note that most calculations do not include staff time wasted accessing the binders and searching for the paper copy.

Make sure you also see Checklist #2: How Well Can You Use Your Policy Management System?

Nicola Heslip | Certified Professional in Healthcare Quality | PolicyMedical

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