Health Information Compliance Alert

Published on Mon Jan 28, 2008 PDF

Here's how two facilities make policy updates a click away.

Electronically accessible manuals go far toward ensuring up-to-date policies and the widest possible distribution to hospital and physician practice staff.

Go green: There is no question that online manuals have saved trees. Before putting their document management system (DMS) online for employees, Pam Avery, RN, BSN, policy coordinator at Enloe Medical Center, in Chico, CA, says that there were up to 150 manuals in the facility, requiring 150 revisions each time a policy was changed, deleted, or added. Now, says Avery, there are only "a few paper manuals around" in supervisor offices within Enloe's seven facilities, including acute care and separately housed rehabilitation and behavioral health buildings.

Enloe's goal has been to put online every organizational document that needs to be available and repeatedly upgraded, Avery explains. In practice, a lot of these policies apply mostly to the nursing staff, she adds. The DMS allows nurses to "pull up and print out" physician orders that the doctor then fills in.

Human resources policies are also easily available and include topics such as leaves of absence, health benefits, and vacation policies. Several of these documents define policies that speak specifically to the needs of contract nurses. While Enloe's DMS does not include union contracts on its intranet site, its HR policies do reflect contractual agreements.

What you can omit: Detailed medical staff policies and bylaws are less likely to be found in the online manuals, says Avery. However, Enloe's DMS does include the peer review policy for physicians, as well as the list of all phone numbers, an essential tool for the nursing staff. Physicians can also find their own orders online by putting their name into the search engine, but the system does not yet allow them to fill out their orders electronically.

A major benefit of online manuals, Avery says, is speed: When a policy is signed, it's on the DMS within a day. Staff, then, must be alerted to policy updates and changes. Avery describes a variety of mechanisms designed to "give people the information" and keep staff informed. She sends letters to all department managers; and when a big [policy] issue or change is happening, she asks that a "blurb" be included in the five minute meetings during the nursing shift change. In addition, Avery sends a monthly newsletter to describe these big changes.

Include training: Avery makes sure that new staff orientation includes information about the online policies and the methods for accessing them. The medical center also includes database training in their nursing skills fairs. But Avery acknowledges that some hospital staffers may not be computer savvy or may simply find the online manuals difficult to access. For Avery, the answer is to find someone to ask. "There are always employees who say they "didn't know," but it remains the employee's responsibility to contact someone who does know: Their managers, their charge nurse, or Avery herself, who is available in person and on the phone.

Create your own: The key to any online manual, of course, is navigation and easy search. Avery created Enloe's DMS in collaboration with a local software company. The process began with a huge Excel file containing many subfiles. Once the DMS went online, she found that she would need to make small changes to improve accessibility for the staff. The initial program cost "in the thousands," but as long as the program itself does not need to be changed, uploading information is not costly. Avery currently maintains the database and is able to make small changes while maintaining the integrity of the other sections.

For larger facilities, the efficiency is multiplied but the complexities are even greater. At the University of Illinois Medical Center at Chicago (UIC), there are three layers of policies, one reflecting the university, another its very large Chicago campus, and the third, the medical center itself.

Don't miss: While all three policy "layers" are electronically accessible, explains Kathleen Mika, RN, MSN, assistant director, compliance and staff development, at the UIC Medical Center, the complexities of putting policies and procedures online increase. Still, having policies electronically accessible is crucial, Mika points out, because "leadership has a responsibility to communicate policies and procedures to staff;" and access while not mandated by The Joint Commission, must be online since this is the only way to keep the manuals accurate and up to date.

Mika explains that her facility follows The Joint Commission standards in organizing its online manuals. For instance, the online policies include chapters for the disaster manual, compliance programs, and clinical guidelines.

Helpful: Human resources information is also extensively listed, including orientation checklists, information about campus and university level benefits, and forms needed for payroll deductions and savings plans. To standardize public relations and marketing efforts across the medical center, the Chicago campus, and university, there is also a "marketing tool kit" which contains logos and color options for documents expected to be published.

Try this, too: The medical center online site includes a listing of physicians, including the credentials, privileges, and practice locations.

These online policies are very comprehensive, but just as at Enloe, the goal is to encourage their use. Orientation materials and other training manuals include focused assistance on accessing information electronically. Currently, Mika says, the manuals are only in English, but the center is looking into multilingual versions. As in the smaller facility at Enloe, there are only a few hard copies around the medical center, and employees with questions are urged to go to their supervisors.

Snag: The multiple layers of policies, Mika points out, makes electronic navigation even more complex than it might be for other medical centers. "We want better ways to facilitate integration to have better access to policies."

Tip: The key, Mika says, is cross-referencing and navigation. As a result, there is special emphasis on the key word function and thinking the way a searching employee might.

"Having a policy online doesn't necessarily accomplish the goal [of accessibility]," Mika points out, because the information "must be presented in user-friendly format."

Plan ahead: The UIC Medical Center has in place a multi-step process for changing policies and adding them to the online manual. Once the policy has been approved officially, its "designated owner" fills out a template, which eventually makes its way to the online manual. The template format, says Mika, simplifies the online revisions.