1. Leaning Out the Nursing Policy and Procedure Process
Paula F. Coe MSN, RN, NEA-BC
Director, Center of Nursing Excellence and Innovation
Gregory M. Gurican RN, MS, MBA Manager - Nursing Quality Management & Innovation, Center for Nursing Excellence and Innovation

2. Application of L6S Tools
What We Learned:
Value Stream Mapping: (Eliminate Waste)
Interview Stakeholders
5-S: (sort, set, shine, standardize, and sustain) SIPOC: Supplier, Input, Process, Output, and Customer (defining values)
A-3: (defining the issue, background, current conditions, problem analysis [5 Why’s], setting a goal, targeting the new state, overcoming barriers, and determining the implementation plan.)

3. The Issue (Value to the Customer)
Significant delays in the distribution and posting of newly revised or created Nursing P&Ps to the INET. (n= 400+ )
Annual review of nursing P&P per DOH and other regulatory bodies as applicable
Delays in posting up-to-date Nursing P&Ps can potentially affect:
Patient care
Patient safety
Regulatory Compliance
Staff /Policy owner satisfaction
SDM Council efficiency/effectiveness/workflow

4. Key Points Current process is inefficient and flawed and not working
Sources of Waste:
Multiple handoffs (process time)
Duplication of efforts
Multiple reviews
Time delays (caused by re-work, tracking changes, reminder notices, log keeping)
Multiple manual operations
Work-arounds by policy owners
Costs (color printing, hard copy distributions, time)

5. Policy Review & Approval Process
Reviews are Scheduled per P&P ADM-001
Revised P&P must be sent to Council for Approval
Submit to Council 1-month before Required Review month, for minor changes.
Submit to Council 2-months before Required Review month, for major changes.
Responsible party (“Owner”) must present changes to Council.
Council to communicate significant changes to SLs.
Upon approval of P&P with changes, Admin. Asst. assigns page numbers.
Admin. Asst. posts to INET within 1 month of being finalized.
Notes:
1. Consolidate like policies when able.
2. Delete non-applicable policies, requires Council approval.
3. Job change requires re-assignment of Ownership.

6. Processing Reviews
Interviewed CNS policy owners and solicited feedback
Interviewed SDM council chairs for feedback
Interviewed current administrative support
Monthly distribution of all policies requiring review per ADM 001
Number of Policies assigned to specific owners

7. Actual Process Flow

8. No. of Nursing P&Ps for Review

9. Distribution of Nursing P&Ps

10. 5 Why’s…. Delays is Administrative Processing of Policy and Procedures
Lack of standardization without clearly defined role responsibilities and expectations across owner and councils
Each owner and council used a different method to process changes and communicate changes
Wasted time identified in the multiple processing steps
No standardization in formatting of documents by owners and administrative support staff

11. Waste in P&P Processing…..
“Where are we at in the process of the nursing policy review?

12. Nursing P&P Process SIPOC
Supplier
Input
Process
Output
Customer
Nursing P&P Owners
Council Approvers
Administration / Management
Service Line CD
Proposed NEW POLICY Owner
ADM-001 Nursing P&P Manual – “Table of Contents” Procedure Listing
ADM-002 Nursing P&P “Format & Content” Template Doc
Owners recommendations
Reviewers recommendations
Council Chairs recommendations
Management recommendations
MULTIPLE PROCEDURES GOVERN THE PROCESSES:
ADM-002 “Format & Content” Template Doc
ADM-003 Nursing P&P “Development & Review” policy
ADM-004 Nursing P&P
“Database, Access & Maintenance” procedure for storage, and retrieval
Revised and
Updated Nursing P&P Change Processing:
Policy
Guidance
Format & Content
Processing of Changes
Review & Approvals of Changes
Staff RN’s
Management
Councils
Leadership
Regulatory:
DOH JC
External Reviewers:
ANCC /Magnet

13. A-3 Analyses
Issue: The current processing of Nursing P&Ps is backlogged 6-mos., which could lead to potential errors in clinical practice.
Background: The existing cyclic process involves the handling of > 400 policies for review and revisions annually. On average 35 Nursing P&P’s must be reviewed monthly by policy owners, councils and administrative staff. The cycles include multiple communication paths, which generate delays in finalization of procedure changes and ultimate distribution and/or posting to the INET
Current Conditions: Waste is created throughout the process due to the multiple steps involved and multiple individual processes led to lack of standardization which continued to delays and backlogs to increase.

14. Problem Analysis Flawed communications
Wasteful tracking of administrative steps,
Lack of timeliness due to nature of monthly review cycles
Poor spread of workloads over annual review period
Overload of owners and councils related to uneven distributions,
Lack of standardization, without clearly defined role responsibilities and expectations.

15. Targeted Conditions

16. Solutions- Final Thoughts
Nursing Policy regarding review process revised to reflect current workflow and standardized template implemented
Streamlined Process flow and handling will reduce time delays and improve efficiencies and staff satisfaction
Evaluate proposal for system wide implementation of Mosby electronic P&P’s
Evaluate Policy Center SharePoint Portal for WellSpan Nursing specific policies