Managing medical documentation is a complex challenge for health system laboratories, which must maintain document control in order to protect patient privacy, standardize testing procedures and adhere to strict regulations.
Labs often have thousands of policies that undergo frequent revisions; ensuring that management and staff can find needed policies requires a high level of commitment.
In a November Becker's Hospital Review webinar sponsored by RLDatix, three document compliance experts discussed Sharp Laboratory Service's document control journey, shared examples from other health systems and suggested best practices for document control systems.
Presenters were:
- Kathryn Biasotti, principal, KB Consulting
- Cheryl Kirchner, director compliance solutions, RLDatix
- Tamara Westgate, document control specialist, Sharp HealthCare in San Diego
Three key takeaways were:
- Sharp Laboratory Services transformed its cumbersome hard copy-based documentation system into a standardized electronic document control solution. According to Ms. Westgate, in 2005, the organization had no master file or network repository. "We had about 1,500 policies at that point," she said. "We had to go and search for hard copy binders at every location. We had handwritten changes on hard copies, multiple versions across our system and missing updates. We had staff who hadn't been updated on processes, which could potentially lead to testing errors, and we had no electronic reporting system or new employee transfer of knowledge."
Sharp began moving files to PDFs and eventually into a homegrown content management system. "This was a huge step forward," Ms. Westgate said. "Now, all of our documents could be uploaded, and we had approximately 20,000 employees who could access, search and run reports against those policies. We could now send automated notifications to our medical directors when we needed to do approvals.
"When we moved to PolicyStat (from RLDatix), we really started reaping the rewards of document control," she said. "We were able to standardize our forms, meet regulatory requirements, break down details by each lab area and conduct more extensive reporting. It forced everybody to come together as a system, which allowed for maintaining ongoing regulatory compliance. Our medical directors love to be able to make comments or change requests online if they don't approve a policy right away."
- Other laboratories shared key lessons from their document control journeys. "The lack of communication was one of the central issues at Health Network Laboratories," Ms. Kirchner said. "The leadership and front-line users were split, which created a struggle and tension in their organization. Their innovations were a result of listening to the internal customers, documenting as they went and following up on the recommendations of the front-line staff."
Wisconsin Diagnostic Laboratories' goal, on the other hand, was to consolidate and simplify with PolicyStat. "They categorized their documents into standard areas, consolidated similar lab types and implemented a tiered workflow system that added more approvers as needed," Ms. Kirchner said.
- Best practices should focus on comprehensive, standard and searchable policy creation, revision and management.
Best practices include:
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- Universal search. "It's important to provide efficient access for all staff to look up policies and guidelines in this ever-changing landscape," Ms. Biasotti said. "Universal search in a policy management system can be so incredibly helpful, and driving auditing and validation of policy adherence to attestation is key."
- Surveyor standardization. Be sure surveyors have easy access to current policies and procedures, streamline survey-preparation processes and link policies and documents to respective standards.
- Archive policies. "The ability to archive policies electronically for litigation requests becomes important when your attorney requests a policy that's several years old and has undergone several revisions," Ms. Biasotti said. Reviewing policies that are linked to safety events, patient complaints or claims can further drive learning and improvement initiatives.
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Having an effective document control management solution can help streamline and standardize the creation and updating of thousands of laboratory policies that can help ensure consistent testing and increase regulatory compliance.
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