Prescription for Change

16K documents, 1 platform: How the Cleveland Clinic overhauled policy management

by Gabbie DeCuir

An underperforming policy management system is more than just an administrative issue—it can also jeopardize an organization’s care quality. Redundant, conflicting documents prevent clinicians from locating the correct policies and procedures, ultimately inhibiting reliable care delivery.

Like many organizations, the Cleveland Clinic struggled with document mismanagement. The organization lacked standard policy approval, creation, and review processes, and as a result had many inconsistent and outdated policies throughout the system. Recognizing the severity of the issue, the Clinic’s policy office launched an initiative in September 2013 to overhaul the organization’s policy approval and document management processes.

This initiative has been an overwhelming success; the Clinic has made significant progress in eliminating duplicate documents and standardizing policies across the system so that all caregivers can access—and act on—the same information.

The Cleveland Clinic followed a five-step process to overhaul its document management system-wide.

Step 1: Take inventory

First, the Clinic’s policy office created a Policy Strategy and Implementation Task Force to help shape the organization’s document management strategy. The task force took inventory of all existing policies across the system and found that there was no central repository for storing policies. They also identified three additional major areas of potential risk to the organization: the document management process itself, communication and education around new and revised documents, and auditing the document inventory. The task force prioritized the following action steps to reduce the organization’s risk in these three areas.

Step 2: Create a single repository

Storing documents in a centralized location ensures that staff from all facilities across the organization can access—and follow—the same policies. When choosing a centralized platform, the task force evaluated all options against a number of necessary functionalities, like the ability to find policies quickly and send out policies to staff across the system. The task force chose an electronic platform called Policy and Procedure Manager (PPM) and mandated its use to the majority of facilities across the organization.

Once the central repository was identified, staff from the policy office transitioned all documents from the Clinic’s main campus into the platform. In addition, the task force standardized document types and definitions and created templates for each.

Step 3: Educate staff

Once the central repository was in place, it was important to inform staff about procedural changes that affect their day to day practice. The Clinic’s policy office created a Policy Communication and Education Team to educate staff on how to use PPM. This team created a suite of tools for staff at all levels—including organization leaders, document owners, and broader staff—to teach them how to locate policies on the new system and write policies in line with the new standards.

Step 4: Audit policies

Once PPM was rolled out, the policy task force required document owners to remove redundant policies from the platform. They also built alerts into the system to notify document owners of an upcoming expiration date so owners can review and update policies as necessary.

Step 5: Track progress

The Clinic currently assesses its progress by tracking metrics like document flow and standardization. Since transitioning to PPM, the Clinic has realized a significant reduction in the number of documents in circulation, from 22% to 65% depending on the department.

The Cleveland Clinic’s document management initiative has been extremely successful. All mandatory documents across the system—totaling over 16,000—are now housed on a single platform and can be accessed by staff at all facilities. The organization has also made significant strides in standardizing its policy and procedure documents system-wide, which continues to be an ongoing priority.

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