Abstract

43 Background: Institutional policies serve as a fundamental framework that enables staff to fulfill their roles and responsibilities. A comprehensive analysis of 5 months of policy access log data extracted from Ellucid, our policy management system, showed that the average views per updated pharmacy policy ranged from 0 to 3 within the 7-day period following the updates. These findings reveal a notable lack of visibility and limited user engagement with policy updates within the pharmacy department, which consists of approximately 300 staff members. To bridge this gap and enhance policy communication, we aim to keep pharmacy staff well-informed and provide easy access to the most up-to-date policies at Dana-Farber Cancer Institute. Methods: The study employed the Plan-Do-Study-Act (PDSA) cycle methodology to guide the quality improvement process. An assessment of preintervention data from the policy access log was conducted to identify the problem. Subsequently, a survey was designed and administered to evaluate staff’s ability to navigate the policy management system, their awareness of policy updates, and their preferred communication channels for receiving updates. Descriptive statistics were utilized to summarize the survey responses, providing valuable diagnostic data. Additionally, a Statistical Process Control (SPC) chart was employed to monitor the process change over time, ensuring ongoing improvement. Results: The survey was distributed to select pharmacy staff in various areas, with a response rate of 30% (13/42). The majority of participants (80%) indicated that email is their preferred communication method for receiving policy updates on a quarterly basis. In the first cycle of the PDSA, an email communication channel was established using the Staffbase program to disseminate policy updates and was piloted within the pharmacy department. The email communication included a summary of all pharmacy policy updates from the past three months, with key changes highlighted. Each policy was attached with a hyperlink directing staff to the full policy on Ellucid, facilitating convenient access. Staff were also provided with education on navigating the communication email. These interventions resulted in a two-fold increase in the policy access rate compared to the baseline. Conclusions: The implementation of a formal communication channel for policy updates, along with improved accessibility to relevant content, successfully enhanced pharmacy staff access to policies. Ongoing monitoring of the policy access log will be maintained to ensure the sustainability of these improvements in the future.

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