YNHHS policy standardization effort kicks into high gear

Yale New Haven Health has more than 3,000 policies, covering everything from how kidney transplant recipients are evaluated at YNHH, to visiting Greenwich Hospital’s maternity unit, to hiring for the health system – and numerous other topics.

Many of these policies are on YNHHS’ online Policy Manager; others are in binders on departments’ shelves; and still others are on individual departments’ SharePoint sites.

Recognizing the need to streamline and reorganize its policies, YNHHS last spring launched a policy standardization effort that will ultimately take 18 months and involve dozens of staff from different roles, departments and delivery networks, along with physicians. After receiving training on a consistent approach to system policy standardization, teams of participants started their work last October.

“The teams will do much more than pare down and organize policies,” said David Depukat, RN, manager, YNHHS Accreditation and Regulatory Affairs. “Members will use their expertise and experience in the various clinical and non-clinical areas to evaluate, revise and streamline policies that set systemwide standards.”

The first steps in the policy standardization effort involved identifying and categorizing current polices. Reviewers discovered that in some cases, different delivery networks have many different policies covering the same topic. To further complicate matters, a number of the nearly 12,000 files in the online Policy Manager were not policies, but procedures, manuals, educational materials or other types of documents. The number of items in the database has since been reduced to around 7,000 highly regulated documents, Depukat said.

For the standardization project’s next steps, teams will thoroughly review each policy, determining whether it should be integrated with similar documents to create a health system policy, or if it’s needed at all. It will be intricate and important work, said Marjorie Guglin, RN, vice president, Clinical Project Management.

“Policy standardization is fundamental to being a true ‘health system,’” she said. “It’s fundamental to having a Yale New Haven Health care signature.” Watch for more information about the policy standardization effort.