Change is coming: The road to policy governance reform

Michigan Medicine’s executive leadership has recognized the workforce’s frustration with trying to access the tools and resources they need to provide the best care for our patients.

FACT: 40 percent of safety events have a common cause in policy, protocols or processes.

Staff either don’t know a policy exists, or do know and can’t find it, or find too many or find a confusing document. This is a real source of frustration for staff and leaders, especially for the patient experience.

Some websites have broken links to policies, while others are taking longer to locate.

“There are several policies out there that are owned by groups, departments or others that need to eventually be moved. It will be so great when all the policies are in one place and the links no longer can be broken, ” said Beth VanTiem, R.N., of 11W at C&W.

So what has been done to solve the problem?

A workgroup was convened to look at the problem. They found that policies, procedures and guidelines were scattered over 60 websites (that they know about). The websites didn’t talk to each other, and approval pathways were needlessly complex and muddled.  

As a first step, the organization purchased PolicyStat, a tool for managing policies, procedures and other important documents.

Designed as a “one-stop shop” to provide the workforce with the information they need when they need it, PolicyStat is a web-based tool accessible from any device that can connect to the internet and provides a systematic review and approval process with document red-line editing and version control. 

The workgroup also recommended the formation of an Inter-Professional Policy Committee (IPPC), which is charged with building a framework for policy governance, including approval pathways. An important first task will also be adjudicating the current universe of PP&Gs that are residing in PolicyStat when everyone is done putting their PP&Gs into PolicyStat.

“The IPPC is truly interdisciplinary and brings the voices of all of us who take care of patients, as well as those that are experts in clinical operations, compliance, legal, regulatory readiness, human resources, and informatics to the table to help us fix these issues and find a path forward,” said Peg Hill-Callahan, clinical policy manager at Michigan Medicine.

Once the committee solves the pain points and builds a new framework, the committee’s role will shift into approving clinical PP&Gs that are multi-disciplinary and/or have system-wide impact, as well are serving as consulting partners to colleagues who are doing clinical policy work throughout the health system. 

What does the reform mean for the organization?

• Reduce administrative burden at all levels
• Reduce regulatory and accreditation risk
• Increased productivity/savings in effort by reducing overall time spent in committees discussing, debating and approving PP&Gs
• Improve consistency in clinical practice across our enterprise, with corresponding improvements in:
  • Patient experience
  • Productivity/value created through our work processes
  • Quality and patient safety, leading to reduction in safety related events
• Improve the organization’s culture of accountability
• Improve staff and faculty engagement and satisfaction

“With only a handful of departments’ documents in PolicyStat so far, we’re already seeing areas of overlap and conflict,” said Cathie Joynt, project lead for the PolicyStat implementation. “Once we get more areas to upload their PP&Gs, the IPPC will be able to see the full picture and they’ll be able to make steady progress toward building a framework for clinical PP&Gs which will make finding information so much easier for everyone.”

This transition is also in alignment with Michigan Medicine’s journey to high reliability. By having one centralized location for all policies, procedures and guidelines, it will create a stronger safety culture where employees are the first line of defense against mishaps and errors.

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