eHealth Articles & White Papers

Implementing a Policies and Procedures Management System

Angie Brunow - Senior Project Manager

Geonetric's new electronic Policy and Procedure Manager makes it easy for hospitals and health systems to organize and update policy and procedure documents. When implementing the software, there is always the challenge of how to get started-you need to create a plan, clean-up existing policies and modify your processes.

Here's a list of items for you to consider prior to installing a policy and procedure system, regardless of the software you plan to install.

Timeline and scope

• Determine the policies you plan to include (i.e., all polices, all department policies or only the ones related to The Joint Commission).
• Consider how you plan to roll out the system - with a 'big bang' or phased approach.
• Check out available resources ( i.e., staff, time, etc.) for building your policies into the new system. Do this prior to your "go live" date. Determine if you need to take advantage of build assistance from your vendor. Keep in mind that many staff will continue to do their 'full-time jobs' while working on this project. Be realistic.

Access

• Consider who will build and maintain your policy and procedure system. You should authorize and train users prior to the start of your policy build. Create usernames and passwords that are consistent with their other network logins.
• Make sure to set up a secure - and possibly remote - way for users to access the system. You will also need to think about the security roles/rights. A limited number of people should need centralized control; however, be sure to allow users enough access to do their jobs effectively.
• Determine the saved searches that will help users to quickly find frequently used policies.

Workflow

• Identify your process for reviewing, updating, and writing policies, and then determine to what degree you want to add this to the policy and procedure manager. Keep in mind there may be different rules for different types of policies (e.g., The Joint Commission Standards vs. department policies). Possible workflow data includes: the review cycle (annual, biannual etc); members of the review process (committees, individuals, departments); due dates; the person responsible for final approval; and the people who need to receive the email notifications.

Building policies in the system

• Create a consistent naming convention for your policies. You may include the department name in the title if there will be multiple policies with the same/similar names. Or, you may allow only one policy with multiple addendums or attachments for the variations (this involves identifying duplicate policies).
• Create a consistent look for your policies, perhaps using an approved template.
• Select the format you will use for viewing policies (e.g., Microsoft Word or Adobe PDF). Note: if you load policies in PDF format, make sure all policy builders have access to a PDF converter.
• Gather all the meta data that will be included in your policy record (e.g., review dates, ID numbers, related Joint Commission chapters, categories and keywords used for searching, etc.).
• Decide how you will access old versions of your policies. If you plan to document historical data, you must find a consistent place to store that information in your new system.
• Gather references or attachments that will be related to your policies.
• Determine which policies are related to each other so they can be linked in the new system.
• Identify the most efficient way to build the system taking into consideration future maintenance. Create a system structure that requires you to access only one place to make an update. If your system utilizes group functionality, this may be helpful for updating employee information.

Hardware

• Make sure you have the computers/printers needed at the employees' workstations.

Downtime procedures

• Determine how you will prepare for downtime. You can schedule a regular backup of the policy and procedure system to a disk or file; dedicate a downtime computer and printer (it should be connected to emergency power and have a scheduled backup file loaded on a regular basis); or periodically print a back up paper book (remember those?).

There is more to implementing a new policy and procedure manager than simply uploading the policies and documenting some data. This will most definitely be a process that you will continue working on long after your new system is live, and like any good process, you will learn a little along the way.