Progressing Towards Policy Processing Perfection: A Journey to save an author’s sanity, returning them to work, safely

Quality Improvement Poster Download

Background & Problem

When I joined the Trust in February 2016, there was a lack of consistency in how the policy team operated together, captured information and in how we supported authors of policy documents in the Trust.

We wanted to take the opportunity of this improvement project to have an in depth look at the changes we could make to our processes and how that impact could improve the support we gave to authors.

For their part, staff authoring or reviewing trust policy documents, do so in addition to their main role within the Trust and so their time is under pressure and yet out of date policy documents may contain incorrect information and therefore may put patients and staff or the public, at risk.

Authors contact the Policy team for advice, as they find the policy, accompanying documents and the overall process confusing and would often send us their incomplete documents, for our opinion.

The result was that the process took longer than the Trust’s preferred 12-week time frame and the number of out of date documents in the Trust, were increasing.

Aim

Implement changes to policy team processes and documentation and through those changes, improve support for authors so that 50% of all policy documents are completed within Trust’s 12-week time frame, which in turn would create more time for the policy team to focus upon the reduction of out of date documents, overall.

Method

An Initial audit was undertaken to establish baseline data from historical documents uploaded to Policy Library between Mar-Aug 2016. Following interviews with authors, policy leads in various departments, the Trust Library Manager and policy team colleagues, improvement changes were identified and began to be introduced via a PDSA cycle between November 2016 – February 2017.

Results

• 136 policy documents ( 61.5% of total) were processed within the 12-week time frame.
• Volume of documents processed increased from 16% to 47%.
• Author’s no longer routinely cc the policy team during consultation with colleagues reducing the average amount of emails from 10.5% to 8.5. % per document.
• The number of out of date documents being processed has increased from 29.8% to 70.1%.
• Following our changes, Author’s tell us they are more confident to drive the consultation and approval process with colleagues to meet the 12-week timeframe and that they better understand each step of the process.
• The Policy team processes are now transparent and accessible to the whole team.
• There was a spike in the number of minor amendments and extensions to review dates processed, due to the CQC visit in January.

Implications

Understanding how authors experienced the review process enabled us to make changes and be more transparent, in terms of the system we all needed to follow. It’s involved a lot of education and then listening to adjust where the biggest hurdles to success were. Improved communication via quarterly meetings first established with the Paediatric Policy Group have proven to have had a real impact in terms of the number of out of date documents, with almost all now ‘in date’. We have expanded this to meet with the HR and Maternity policy leads to continue to educate and support their authors and work with them to review their out of date documents.