University Hospitals cuts 2,812 policies

In the last four years, Cleveland-based University Hospitals has sought to reduce administrative burden and clinical guidance inconsistencies through an audit of thousands of systemwide policies. 

As of July, the system has retired 2,812 policies it described as duplicative, burdensome or both.

Oftentimes, the organization’s policy did not reflect each facility’s capabilities, according to Khaliah Fisher-Grace, PhD, RN, director of system policy, quality improvement and operations. 

For example, University Hospitals found misalignments on policies regarding temperature and humidity monitoring. Some hospitals have building automation systems, while others rely on people to perform documentation, such as at older campuses, she added. 

“One hospital didn’t need to have a separate policy that addressed their manual process and another their automated process,” Dr. Fisher-Grace said. “We can just combine all of that in one document.”

Jennifer Gonzalez, program manager of nurse innovation at University Hospitals, said committees within UH’s nursing governance council focused on the front-line work environment. They asked, What does not bring value to your work? What is repetitive? What task or administrative burdens are you exposed to every day? 

“We were quick to change a policy without looking for evidence or exploring the problem completely,” Ms. Gonzalez told Becker’s.

Dr. Fisher-Grace affirmed this culture of “reactive” policy, adding that “despite best efforts, sometimes just changing one sentence or adding one statement can change the workload for the thousands of caregivers that we have, adding to burden overall.”

Other policies that required editing included the frequency of checking vital signs and hand hygiene. There were differences among medical specialties, departments and hospitals, but no evidence-based reason for the variations. 

Dr. Fisher-Grace said the policy reviews occur monthly, and the effort has saved the 21-hospital system approximately $1.2 million. 

“Having that structured process for policy review at all levels of the organization — system, entity, department — I think has propelled our organization forward in so many ways and helped us come together as a system and more committed to zero harm,” she said. “[We] really try to focus on, What are we saying are our mission, vision and values, and how is that being viewed in written documents?”

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