Leaning Out the Nursing Policy and Procedure Process Paula F. Coe MSN, RN, NEA-BC Director, Center of Nursing Excellence and Innovation Gregory M. Gurican RN, MS, MBA Manager - Nursing Quality Management & Innovation, Center for Nursing Excellence and Innovation

Application of L6S Tools What We Learned: Value Stream Mapping: (Eliminate Waste) Interview Stakeholders 5-S: (sort, set, shine, standardize, and sustain) SIPOC: Supplier, Input, Process, Output, and Customer (defining values) A-3: (defining the issue, background, current conditions, problem analysis [5 Why’s], setting a goal, targeting the new state, overcoming barriers, and determining the implementation plan.)

The Issue (Value to the Customer) Significant delays in the distribution and posting of newly revised or created Nursing P&Ps to the INET. (n= 400+ ) Annual review of nursing P&P per DOH and other regulatory bodies as applicable Delays in posting up-to-date Nursing P&Ps can potentially affect: Patient care Patient safety Regulatory Compliance Staff /Policy owner satisfaction SDM Council efficiency/effectiveness/workflow

Key Points Current process is inefficient and flawed and not working Sources of Waste: Multiple handoffs (process time) Duplication of efforts Multiple reviews Time delays (caused by re-work, tracking changes, reminder notices, log keeping) Multiple manual operations Work-arounds by policy owners Costs (color printing, hard copy distributions, time)

Policy Review & Approval Process Reviews are Scheduled per P&P ADM-001 Revised P&P must be sent to Council for Approval Submit to Council 1-month before Required Review month, for minor changes. Submit to Council 2-months before Required Review month, for major changes. Responsible party (“Owner”) must present changes to Council. Council to communicate significant changes to SLs. Upon approval of P&P with changes, Admin. Asst. assigns page numbers. Admin. Asst. posts to INET within 1 month of being finalized. Notes: 1. Consolidate like policies when able. 2. Delete non-applicable policies, requires Council approval. 3. Job change requires re-assignment of Ownership.

Processing Reviews Interviewed CNS policy owners and solicited feedback Interviewed SDM council chairs for feedback Interviewed current administrative support Monthly distribution of all policies requiring review per ADM 001 Number of Policies assigned to specific owners

Actual Process Flow

No. of Nursing P&Ps for Review

Distribution of Nursing P&Ps

5 Why’s…. Delays is Administrative Processing of Policy and Procedures Lack of standardization without clearly defined role responsibilities and expectations across owner and councils Each owner and council used a different method to process changes and communicate changes Wasted time identified in the multiple processing steps No standardization in formatting of documents by owners and administrative support staff

Waste in P&P Processing….. “Where are we at in the process of the nursing policy review?

Nursing P&P Process SIPOC Supplier Input Process Output Customer Nursing P&P Owners   Council Approvers Administration / Management Service Line CD Proposed NEW POLICY Owner ADM-001 Nursing P&P Manual – “Table of Contents” Procedure Listing ADM-002 Nursing P&P “Format & Content” Template Doc Owners recommendations Reviewers recommendations Council Chairs recommendations Management recommendations MULTIPLE PROCEDURES GOVERN THE PROCESSES: ADM-002 “Format & Content” Template Doc ADM-003 Nursing P&P “Development & Review” policy ADM-004 Nursing P&P “Database, Access & Maintenance” procedure for storage, and retrieval Revised and Updated Nursing P&P Change Processing: Policy Guidance Format & Content Processing of Changes Review & Approvals of Changes Staff RN’s Management Councils Leadership Regulatory: DOH JC External Reviewers: ANCC /Magnet

A-3 Analyses Issue: The current processing of Nursing P&Ps is backlogged 6-mos., which could lead to potential errors in clinical practice. Background: The existing cyclic process involves the handling of > 400 policies for review and revisions annually. On average 35 Nursing P&P’s must be reviewed monthly by policy owners, councils and administrative staff. The cycles include multiple communication paths, which generate delays in finalization of procedure changes and ultimate distribution and/or posting to the INET Current Conditions: Waste is created throughout the process due to the multiple steps involved and multiple individual processes led to lack of standardization which continued to delays and backlogs to increase.

Problem Analysis Flawed communications Wasteful tracking of administrative steps, Lack of timeliness due to nature of monthly review cycles Poor spread of workloads over annual review period Overload of owners and councils related to uneven distributions, Lack of standardization, without clearly defined role responsibilities and expectations.

Targeted Conditions

Solutions- Final Thoughts Nursing Policy regarding review process revised to reflect current workflow and standardized template implemented Streamlined Process flow and handling will reduce time delays and improve efficiencies and staff satisfaction Evaluate proposal for system wide implementation of Mosby electronic P&P’s Evaluate Policy Center SharePoint Portal for WellSpan Nursing specific policies