Over the last four years, Cleveland’s University Hospitals has been actively working to lessen administrative strains and inconsistencies in its clinical guidelines. It opted for an extensive audit of thousands of policies system-wide. As of July, it was announced that the system had phased out 2,812 policies that were categorized as duplicative or burdensome, or a combination of both.
Khaliah Fisher-Grace, PhD, RN, who serves as the director of system policy, quality improvement, and operations, explained that much of the reason behind the redundancy and ineffectiveness in policy was because the organization’s policy did not consistently mirror the capabilities of each of its varied facilities. Delving into specifics, discrepancies were noted in policies concerning temperature and humidity monitoring protocols as per different facilities’ functionalities. Technologically advanced hospitals with building automation systems didn’t require the same individual documentation as older campuses. Fisher-Grace illustrated this with an instance stating, ‘One hospital didn’t need to have a separate policy that addressed their manual process and another their automated process. Instead, a single comprehensive policy document would suffice.’
Jennifer Gonzalez, program manager of nurse innovation at University Hospitals, added that many committees within the organization’s nursing governance council put a spotlight on the front-line work environment, seeking to understand redundancies and administrative burdens healthcare professionals faced on a daily basis. According to Ms. Gonzalez, a rapid change in policy was often undertaken without thorough evidence-based exploration of the problem. Surprisingly, this knee-jerk reaction could inadvertently burden front-line caregivers.
An example of this was seen in protocols dictating frequency of hand hygiene and vital sign checks. These protocols varied across medical specialties, departments, and hospitals despite having no evidence-based rationale to justify such differences. To maintain optimal policy alignment, monthly policy reviews have been instituted. This approach has reportedly saved the healthcare system around $1.2m.
Fisher-Grace attributed the organization’s forward momentum and increased commitment to the zero-harm initiative to the structured policy review process at all organization levels – system, entity, department. The institution is striving to align its policy guidelines with its mission, vision, and values, while ensuring these values are duly represented in policy documentation.
Source: https://www.beckershospitalreview.com/quality/university-hospitals-cuts-2812-policies/