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Efficient Policy & Procedure Management -- a Cedars-Sinai Case Study

This study reviews the document management challenges faced by this hospital before installing PolicyTech's Policy and Procedure Manager (PPM).


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In healthcare organizations large and small, policies and procedures are a critical part of the foundation for success Cedars-Sinai Health System (CSHS), a non-profit hospital in Los Angeles, recognized this need.

They must be current, accessible and reliable to users because they contain the key procedures and processes that produce excellence. An outdated, inaccessible, or poorly communicated policy or procedure is often the main factor in a quality or compliance issue.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 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.

The Challenge: Complex policy Management
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.
  • 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.

The Solution: Using PolicyTech to Support an Effective Model
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, also gave its exclusive endorsement to NAVEX Global’s PolicyTech.

The Results: Eliminating Policy Clutter and Confusion

  • Currently 97%, of all policies, procedures, forms and job aids reside in PolicyTech.
  • 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.

To learn more about this successful implementation, download the full case study.