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Regulatory Issues

Web-based solution helps hospital keep up with regs

Managers at a 25-bed critical-access hospital hoped the software could make regulatory surveys smoother by addressing their three biggest challenges.

ccreditation bodies, such as the Joint Commis- sion and Centers for Medicare and Medicaid Services (CMS), stress the importance of fol- lowing policies and procedures for providing safe, quality patient care. These bodies conduct frequent regulatory surveys to ensure hospitals fall in line with their own standards as well as those required to achieve national patient-safety goals.


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To keep up with pertinent standards and regulations – but most importantly, to provide the best possible care for the

patient – St. Vincent Randolph, A 25-bed acute-care facil- ity serving the residents of Randolph County, Ind., chose to implement PolicyStat’s web-based policy and procedure- management software in early 2011. Managers at the 25- bed critical-access hospital hoped the software could make regulatory surveys smoother by addressing their three biggest challenges: 1. Making policies more easily accessible to staff by putting a centralized, easily searchable repository in place to organize and store policies;

2. Increasing accountability by ensuring associates refer to policies and by holding policy authors accountable for editing and updating policies within the appropriate timeframe; and

3. Standardizing policies throughout not only the hospital, but also with other hospitals across the St. Vincent Health system.

Director of Human Resources Zach Matthews and Chief Nursing Offi cer Carla Fouse were charged with getting poli- cies and procedures up and running in the PolicyStat system. “When PolicyStat came to present their product, I knew their system was going to be an immense improvement over our current paper system,” Matthews says.

Surveys Shortly after a recent Joint Commission survey at St.

Vincent Randolph, CMS conducted an extensive validation survey. Normally, CMS comes in with an itinerary and con-

22 January 2012

ducts a “tracer,” where they take a certain population, age group or diagnosis and pull a chart on the nursing unit, for example. They check that standards are being followed – es- pecially in regard to national patient safety goals – then ask associates questions about specifi c policies related to those standards or goals. Each survey ends with an exit interview conducted by the auditors, with results ranging from simple fi xes to signifi cant issues for which an action plan must be implemented.

Surveyors look for different things, but mainly they want to make sure staff knows where each policy is. “It would be very unsafe to the patient if we had associates providing treatment without the ability to consult policies,” Fouse says. “Our goal is to provide safe patient care and to create a culture that promotes safety in all situations.”

Challenge #1: Make policies easily accessible Joint Commission and CMS surveyors ask how associates know about a policy and where they can access it. “We lacked a system that would effectively inform all staff at once about new or revised policies,” Matthews says. Before PolicyStat, managers just made sure to inform associates of new or revised policies at the departmental meetings. Managers would still need to print policies off and hand them to associates. The PolicyStat system made it easy for associates to fi nd and access any policy in any area with a simple, Google-like search function. “With PolicyStat, nursing staff can easily fi nd and access all applicable policies – not just those specifi c to his or her area, but also those in any of the other nursing units,” Fouse says. Before PolicyStat, St. Vincent Randolph also lacked an organized way of housing policies, making it diffi cult to fi nd policies on the spot during a survey. “The surveyors usually gave me a list of policies ahead of time which I could then pass off to the appropriate managers to retrieve,” Fouse says. During the most recent survey, however, auditors asked for policies to be produced right there on the spot. “PolicyStat allowed us to access the requested policies on demand,” Fouse says. After the most recent survey, managers who had not yet started using PolicyStat saw how it could help them


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