Transition From Site-Based to System-Wide Policies

Abstract

Implementation of a system-wide policy approval policy that changes a culture of “they implemented a policy” to “we engaged in implementing the best-practice policy for our site–system to decrease variation and align practice.” This was especially helpful when initiating a new electronic medical record and then a new policy program systemwide. The proposed change was going from site-specific policies to evidence-based, best practice, system-wide policies. Implementation was based on identification of high-risk/liability policies to expired policies and evaluation of sites with no site-specific policies in perinatal or newborn medicine that were acquired by the health system. The outcomes for the performance improvement project included the number of site-specific policies to system, the number of policies in the 360 program to clinical skills, and the policy and order alignment before the EPIC system’s (Epic Systems Corp., Verona, WI) go-live date. Audits also measure clinical implementation success rates. There is currently a policy structure for the St. Luke’s Health System obstetric inpatient units. The implications for nursing practice include alignment of best practices throughout the perinatal and newborn units, sites that did not have policies for reference now have policies for quality and safety reference for practice to partner with their providers and oversight with their patient care, policy structure for the St. Luke’s Health System obstetric inpatient nursing staff for chain of command use when needed.