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access policies faster and make surveys go smoother. They immediately started jumping on board and importing their policies.

Challenge #2: Increase accountability Surveyors want to see an organized and formal policy process for managing policies and communicating them to associates, and they also expect associates to know where to go to fi nd the information they need. To address both concerns, St. Vincent Randolph put a system in place for increasing accountability.

While some hospitals used an intranet database to store and manage their policies and procedures, St. Vincent Randolph was using a completely paper-based system. The paper-based system often led to confusion regarding who was responsible for what policies and when they needed to be updated. With the PolicyStat system, authors are held more ac- countable for editing and updating policies within the ap- propriate timeframe, so that all policies are kept active and applicable at all times. “We’ve seen a night-and-day difference with PolicyStat versus our outdated paper-based policy sys- tem,” Matthews says. “PolicyStat gives us a more organized system with better accountability.” PolicyStat has greatly improved accountability among all associates, not just management staff. Each associate is now able to fi nd policies and print them off within minutes, versus spending more time hunting to fi nd which policies are applicable and active. “There is more transparency for the associates,” Matthews says. “PolicyStat has helped us get all policies in one place, and staff can access policies whenever they want. This is a much-improved process for us.”

Challenge #3: Standardize across the hospital and across the system Before PolicyStat, inconsistencies existed among policies with similar procedures. It was crucial that these inconsisten- cies were resolved – especially before a survey – but it was a tedious process. “We didn’t have an effective way of keeping policies updated,” Fouse says. “All policies had to be updated at the same time, and that was a huge undertaking for surgery and med surg units that had hundreds of policies.” It was also vital for St. Vincent Randolph to standardize us- ing the most current, evidence-based policies and procedures. Time Out, for example, is a requirement on the forefront of many procedures, but it was not outlined the same in all policies. “We had Time Out in the procedures for surgery but not in the med-surg unit,” Fouse says. “When we perform a procedure in med surg, we should be doing it the same way as in the ER and OR.” PolicyStat’s software and the organized implementation process made standardizing policies achiev- able and less overwhelming, helping St. Vincent Randolph to reduce these types of inconsistencies. Using PolicyStat’s applicability feature, authors at St. Vin-

cent Randolph are now able to share and standardize policies across the St. Vincent Health system, borrow policies from other ministries and make them their own. This allows the entire health system to standardize across ministries and use only those procedures which are based on the most current, evidence-based practices.

Using PolicyStat’s applicability feature, authors at St. Vincent Randolph are now able to share and standardize policies across the St. Vincent Health system, borrow policies from other ministries and make them their own.

“Policy writing can be a diffi cult process,” Fouse says. “One of the best things I have found about PolicyStat is the ability to share policies across the system. I can go to their site and ‘borrow’ some of their best practices. I have to customize some of the policy to make it specifi c to our hospital, but the scientifi c process or general principle is there for me to use. It saves us time and effort to have something that already exists out there – we don’t have to re-type or start from scratch.” “We’ve seen policies from other ministries that we hadn’t yet thought of creating, but now we have been able to add them to our system too,” adds Matthews. Sharing across ministries has allowed authors to standardize and share their evidence-based practices with authors in other ministries, ultimately leading to better quality of care for the patient.

Beyond surveys: Reducing risk and achieving organizational goals

Outside of normal standards and regulations, St. Vincent Randolph also takes a proactive approach on their own to reduce risk and improve care for the patient. “We conduct a risk assessment every year by a body called the Nursing Sen- ate,” Fouse says. The Nursing Senate is part of St. Vincent Randolph and includes elected members from each unit. It gives front-line staff shared governance and a say in how nursing provides patient care. One of the goals for this year’s Nursing Senate is to ensure associates know where to go for policies and to encourage the consistent use of PolicyStat. To help reach this goal, members from the Nursing Senate help staff access PolicyStat and show them how to use it. They encourage associates to go to PolicyStat and look something up if they are unsure. “It makes me feel good that they saw this as an issue and decided to work on it,” Fouse says. “Following policies and procedures is vital to providing safe, quality patient care. And that’s what’s most important.”


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