Before RLDatix

Khaliah Fisher-Grace, the Director of System Policy, Quality Improvement and Operations at University Hospitals Health System, said their organization grew quickly. They added 5 hospitals in a two-year span, resulting in inconsistent policies.

"We knew from top down-board to bedside-that we needed to focus on policy, because when you start to explore the contributing factors to really significant issues, policy typically comes up”.

University Hospitals restructured their Academic Value Institute by function, and incorporated Policy as a key functional area of the institute. Dr. Pronovost, their Chief Quality Oicer, directed Khaliah to lead a system initiative to engage leadership in policy.

"We needed everybody following the same policies and going in the same direction. We knew we needed software,” said Khaliah. “Everything was manual, on our intranet and we didn’t have full oversight over all of the hospitals, especially the newer hospitals. So, we knew that we had to really get our leaders engaged around policy.”

Implementing RLDatix’s Policy Management Solution and Partnering with RLDatix Consulting

Their Chief IT Oicer assigned Michelle Movrin, their Director of IT Corporate Business Systems, to support with technical expertise. Khaliah said, “The one thing Michelle told us was, ‘Take advantage of the consulting.’ Michelle is smart. We took Michelle’s advice. And then we met Cheryl.” (Cheryl Kirchner, RLDatix Healthcare Solutions Consultant)

The UH Policy Team led the implementation of RLDatix’s policy management solution. University Hospitals went through an 18-month collaboration with Cheryl, who served as an extension of the small team.

After RLDatix

Created strategic plan for policy and document management across 21 hospitals: Cheryl helped University Hospitals develop:

• Objective and Key Results
• Customized Policy Management Capability Model
• Document Management Framework
• Charters
• Metrics
• Education Program
• Resources

"We worked with Cheryl to move the needle forward and figure out how to sustain things,” said Khaliah. “We had talked about objectives and key results before, but we needed to know how to measure that.”

Cheryl recommended an evidence-based strategic plan for better stakeholder management for their large hospital system.

"When we’re talking to really smart people internally who have a lot of ideas, and they approach and challenge us to do it a different way, we can now stand solid and firm and say we have an evidence-based model to support how we operate,” said Khaliah. “Working with a consultant-that gives us a lot of credibility with our 30,000 employees.”

The plan listed Khaliah, along with Wendy Frasure, Policy System Administrator, and Freda Juba, Policy and Publications Coordinator-both of whom had experience working with organizational policies within UH community hospitals-as members of their project’s objective: Achieve systemness and advance our journey to Zero Harm through disciplined document management.

Standardized policy usage data and advanced policy and document management: Now with access to real-time data centralized in the Policy Management solution, the UH Policy Team shares policy usage data with several policy committees.

By reporting standardized policy usage data at meetings where risk management, patient experience and patient safety data are also analyzed, University Hospitals can now make data-driven decisions-holistically-to improve patient outcomes.

They’ve accelerated document transitions by automating workflows and identifying workflow bottlenecks at specific hospitals, as well as improved staff education by identifying policy gaps with the Policy Management solution’s real-time data, which include but aren’t limited to:

• Policy counts (overdue, pending, due for review, new, retired, revised) segmented by quarter and oversight committee
• Top keyword searches
• Top keyword searches with no results
• Document transition progress segmented by hospital
• Cost of Poor Quality

Cheryl helped calculate their ‘cost of poor quality.’ By tracking the average hours in policy administration and the average hourly rate for their healthcare leaders involved, they’ve calculated their cost savings-in administrative time (20,000+ hours)-from using the RLDatix Policy Management solution.

"We’ve saved over $1.1 million over a four-year period. We update our cost of poor quality report monthly, which further motivates our leadership in their policy work.”

Wendy Frasure, Policy System Administrator, University Hospitals Health System

Grew policy expertise and engagement within organization: Cheryl helped the UH Policy Team identify and develop resources needed to grow policy expertise and engagement at University Hospitals. They’ve launched:

• Formal education series
• Focused education program
• Digital micro-credentials
• Policy clinics and minute clinics
• Forums
• Toolkit
• Newsletter
• Team inbox

"Our first session of the series was, ‘Policy Management Principles,'” said Freda. “The session linked policies to patient safety. Cheryl presented this and many other sessions.”

Their team has been invited to share policy data insights and document management best practices with committees and meetings outside of Policy: Medical Executive Boot Camp; Graduate Medical Executive Committee; Clinical Research Committee; System Accreditation; Safety & Regulatory Committee; Emergency Management; System Codes.

"We know outdated policies and procedures create patient safety and organizational risk,” said Freda.

"We’ve helped them understand the connection between policies and patient safety. They’re the ones out there on the front lines doing the work.”

Freda Juba, Policy and Publications Coordinator, University Hospitals Health System

Before utilizing the RLDatix Policy Management solution, there was no department-level policy centralization. “They were anywhere and everywhere,” said Freda. “At the system level, we had no idea what state they were in. Now we have an auditing process that engages department leaders with a plan. We’ve developed great relationships with the leaders and they reach out frequently for recommendations.”

University Hospitals Health System and RLDatix

The UH Policy Team’s objective to “Achieve systemness and advance our journey to Zero Harm through disciplined document management” required-and succeeded in-engaging University Hospitals’ leaders.

"Policy is a key component to quality and patient experience and safety. Now, our leaders throughout our expanded health system understand policy and we have mutual accountability from board to bedside.”

Khaliah Fisher-Grace, Director of System Policy, Quality Improvement and Operations, University Hospitals Health System

"Dr. Pronovost and our leadership team have been impressed with the alignment of the RLDatix mission, vision, values and safety message with our mission, vision, values and program priorities. This has prompted our team to learn more about the ways we can partner together and potentially expand solutions.”

The UH Policy Team, partnering with Cheryl’s 10-year experience as a registered nurse and two-decade-experience in Quality leadership, have advanced University Hospitals’ journey to zero harm for the more than one million patients who visit every year.

"Cheryl is worth her weight in gold. She walked us through so many things we needed for a 21-hospital system. Without Cheryl, we wouldn’t be where we are today.”