3/31/2016. Is Your Policy Management System Ready For Growth? Steve Hartranft, Memorial Hermann & Josh Kunz, NAVEX Global

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1 Is Your Policy Management System Ready For Growth? Steve Hartranft, Memorial Hermann & Josh Kunz, NAVEX Global About Memorial Hermann About NAVEX Global 1

2 About Memorial Hermann Founded in 1907 Integrated health system Academic affiliation with The University of Texas Health Science Center Houston Medical School Largest not for profit health system in Southeast Texas Hospitals: 13 Employees: 24,000+ Affiliated Physicians: 5,500 How Did We All Get Here? P&P Prior State From Home Grown to Vendor Solution 11 Years ,000 Policies 14,000 +Policies* Every Document was a Policy * Estimate: HR, Lab policies & many department policies were not on line 2

3 P&P Prior State Key Annual Statistics: ~14,000* Policies & Procedures across the enterprise ~10% of policies out of compliance each month 1,064 active policies currently out of compliance 12,000 active and 32,000 archived policies in current system 19% of policies up for renewal in 2012, 26% in 2013, 33% in 2014, and 22% in 2015 * including those not on line Key Philosophies: If P&P adherence is too complex, people will not comply with P&P Findability is key to use (can not find it, will not use it) P&P should enhance, not detract, from efficiency and productivity P&P should be risk control, not risk itself Accountability is critical Standardization and compliance Should not set employees up for failure (too many documents, too long) Project Description & Scope Replace home grown P&P system New capability for managing document lifecycle from development to archiving On line development/ collaboration/maintenance On line employee assessment and testing/attestation Eliminate duplication and standardize P & P Reduce document numbers Systematize Improve accountability Establish clear process and expectations 3

4 Project Scope & Impact Project impacts all employees across the system All active policies & procedures (~14,000) were imported into new system (also archived) 3 year phased project: Phase 1: Create Technology acquisition, process development, accountability expectations defined Phase 2: Implement Technology, training, clean up process Phase 3: Improve Complete clean up survey users, refine processes, audit quality, monitor accountability 3 Year Phased Project Plan Measurable Benefits Quality and Patient Safety Advance Patient Safety as Core Value system wide policies will reduce variation in care processes, create uniform clinical guidelines, protocols, and facilitate their use Eliminate Preventable Patient Harm Guidelines and protocols easily findable and used, education facilitated Achieve and Sustain Full Joint Commission Accreditation Facilitates continuous readiness, easy identification of TJC, CMS related P&Ps 4

5 Measurable Benefits Human Resources Recruit, Develop, and Retain People facilitate & support employee accountability for P&P knowledge and use One Memorial Hermann Aligning work processes throughout system Operational Excellence Achieve Financial Targets Standardized P&Ps improve employee productivity, mitigate legal risks and losses, create efficiencies Measurable Benefits Growth Will enable efficient management of the outcomes of growth including a more complex policy and procedure environment, system is scalable for growth HIPAA Compliance and Education Will support HIPAA audit requirements through the electronic P&P education and testing component, and verification of employee policy education through e signature P&P Development Chart 5

6 Document Life Flow Results Results 42% reduction across the System As of 1/4/16 6

7 Results Accommodating Growth Since new P&P process implemented 2 hospitals added (acquisitions) 2 more opening within a year (new) All lab and health plan documents are being imported into PolicyTech 1 hospital has been re named Numerous free standing out patient locations have been added Accommodating Growth Strategies Localization Software Module Bulk adoption by CEO/CNO of administrative and clinical system wide documents Outreach to non hospital MHHS entities (i.e., health plan, physician group) Accommodating growth through the use of linked documents Pre planning for the addition of new entities 7

8 Accommodating Growth Strategies Collaborative document development and approval process Philosophy of more is not better continual monitoring for document creep Limiting documents published to a site to only those that apply Accommodating Growth Challenges Getting in the loop early Conversion of existing documents with acquired entities Complexity of increasingly matrixed organizational structure Approval of documents by executives leading more than one entity On going Challenges Training Document Creep Quality Control Monitoring entity process Document owner accountability Reaching patient care staff Physicians Protocol, Standing and General Orders 8

9 Summary of Accomplishments Document number decline Removed duplications Major move to systemization and culture change Move away from home grown clinical guidelines Accountability has improved Simplified document development process/workflow Summary of Accomplishments Electronic approval and signatures Awareness that P&Ps are risk control documents Asking do we need this before a document is created or revised Developing auditing process for on going reporting Questions 9

10 Thank you! Josh Kunz, NAVEX Global Steven Hartranft, Memorial Hermann 10