Before RLDatix

Dani Rothrock, a Professional Practice Program Manager, and Jenna Moody, an Accreditation Consultant, partnered to connect their departments at Baptist Health, a 6-hospital healthcare system in Jacksonville, Florida.

"What was at the forefront of both of our implementations was to establish best practices for patient safety and survey readiness,” said Jenna. “We needed to link together our policy health with our accreditation readiness.”

Before RLDatix, communication silos developed across their administration, operations and clinical departments. The lack of accountability and collaboration led to more than 40% of the 2,000+ policies in their decades-long audit program to be non-compliant.

Implementing RLDatix’s Policy Management and Audits & Standards Solutions

Baptist Health chose RLDatix’s Policy Management solution for its streamlined workflows, Lippincott integration, revision acknowledgements and customizable searches. Upon seeing Dani transform their policy management process, Jenna implemented Audits & Standards, RLDatix’s accreditation readiness solution.

Standardized workflows: “They didn’t have one standard workflow,” said Dani. Baptist Health’s users couldn’t remember passwords. They had to leave their legacy system to submit work orders into another system. Now with single sign-on, their users can use personal mobile devices securely to view policies and complete real-time audits. QR codes have further improved user accessibility, and with the Audits & Standards’ integration with Accruent TMS, users can place work orders instantly.

In the Policy Management solution, users can view policy owners, revisions, revisers and the reasonings for those edits-all of which accelerate approvals through improved visibility and communication. Dani uses the comments feature to tag and notify the assigned subject matter experts when a policy has been reviewed, activated and published. With PolicyStatistics, an add-on that features advanced policy management data, their users now receive faster, more relevant access to Baptist Health’s policies. Dani analyzed policy query data, such as most-viewed policies by month and ‘Top Searches producing no results.’ She discovered that many users searched incorrectly, by ID number, which prompted her to teach users to search by keywords. With the Policy Manager’s interactive Table of Contents, their users can now click headers to access desired policy areas instantly.

Formalized accountability: Now every month, Dani shares a policy compliance report- customizable by several parameters that highlight the policies with the highest pending times and number of expiring policies by location, informing Dani on stalled policy workflows. This has reduced expired policies by 68%.

Connected Policy and Practice to Accreditation and Audits: Baptist Health’s policies link to corresponding state standards and elements of performance of the Joint Commission, their accreditation body. When a policy connecting to accreditation is revised and acknowledged, the Policy Management solution sends an automated email to Jenna and assigned stakeholders. The Accreditation Team then reviews audits to ensure policy updates are accurately reflected for compliance monitoring.

After RLDatix

Reduced audits: By consolidating audits, and removing outdated and duplicate audits, Jenna reduced their audit library by 34%, from 307 to approximately 200.

Improved organization of audits: Baptist Health’s users can search various categories, such as ‘Provision of Care’ or ‘Adult Inpatient Nursing’ to quickly identify pertinent audits in a search. Time-limited audits are tracked and removed by the Accreditation Team using categories such as ‘RCA’ or ‘Corrective Action.’

"We were able to do a deep review of that policy, found we needed to change some of the areas, but that would not have been brought to our attention if not for that low audit compliance… Linking together that policy health really does lead to a continuous state of accreditation readiness and patient safety”

Jenna Moody, System Accreditation Consultant, Baptist Health

Improved patient safety and survey readiness: With Audits & Standards, Baptist Health identifies unit, facility and system deficiencies. Their mock and oicial surveys highlighted high-risk, highly cited processes that require more frequent audits. System-level deficiencies are no longer siloed and are addressed through escalation of audit findings, which has led to EMR enhancements and policy clarification. Subsequent patient care policy updates are then shared through communication from their Chief Nursing Oicer across the organization in their monthly newsletter to clinicians.

You can use the Policy Management solution for so many kinds of documents that have a review process.

Dani Rothrock, Professional Practice Program Manager

What’s Baptist Health Doing Next With RLDatix?

Dani is exploring using the RLDatix Policy Management solution for protocols, forms, hot sheets and further educational initiatives to improve their user experience in accessing information.

Baptist Health’s Accreditation Team is using Audits & Standards’ Schedules feature to further drive accountability of audit completion. Annual mock surveys are completed using Assessments, and sustainable improvements are carried out through plans at the unit, facility and system levels.

Their team has enhanced the Insights reports to meet the needs of their Response Managers. The enhancements have been geared towards driving compliance and accountability, showing audit compliance, number completed and progress with finding resolution.

Baptist Health and RLDatix

Jenna and Dani have transformed Baptist Health by improving accountability and connecting their policy and accreditation departments with an integrated compliance solution.

Their established best practices, along with 34% fewer audits and 68% increased compliance in policy expiration dates, have brought patient safety and survey readiness back ‘to the forefront’ at Baptist Health.