YSM Policy and Procedure Process Office Hours Presentation

April 05, 2023

Information

Recording of the general user training and PowerPoint slides.

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00:00Because it is 1/2 hour but
00:02it's a tight half hour,
00:04we have a lot of content to cover
00:07a couple of housekeeping items.
00:09The meeting is going to be recorded.
00:11We're going to post the session on the
00:14help site so that people can view it
00:17in the future due to the time limit.
00:20What I would ask is if you have questions,
00:22if you can enter them into the chat,
00:24Parami will be.
00:25Tracking those and at the end,
00:27if we have time,
00:28we'll go through them and then
00:29if we run out of time,
00:30she will save the questions and
00:32we'll be able to follow up with you
00:34directly with the answers after.
00:35We're also going to consolidate the
00:38frequently asked questions and create
00:40an FAQ for the website as well.
00:43This session is a pretty high
00:45level overview of just how we
00:47got to where we are today,
00:49what started the project,
00:50how the project evolved and then
00:53I'll give you a quick demo of
00:55just how to search for a document.
00:57We will be doing some future sessions
01:00that dive more into policy development
01:02and also the process if you want to
01:06change or alter an existing policy.
01:09But for today this is going to be more
01:10of an overview of the project itself and.
01:13And just to give you a sense of how to
01:14search for documents in the new tool,
01:19okay, I won't go into too much detail here,
01:22but to introduce us in case
01:23you haven't met us before,
01:25my name is Andrea Tenbrink.
01:27I'm the senior director of compliance,
01:28have been with Yale for
01:30about a year and a half.
01:31And Parmi has been with Yale since 2018.
01:34She is our senior policy analyst.
01:37I was fortunate to get her to join
01:39the team and she's definitely an
01:41important part of this project and a
01:43key person for you all to be aware
01:45of if you have questions after or as
01:48you utilize the tool in the future.
01:52So as a general baseline,
01:53I like to, you know, go to the why,
01:56why does document management matter?
01:58And for me, as a compliance person,
02:00it's very important.
02:01Department of Justice and Office of
02:04Inspector General have issued guidance
02:06documents on their expectations of
02:09compliance programs and policy.
02:10And procedure is one of the key 7 elements.
02:13They have an expectation that
02:15you have rules and how to follow
02:18them outline clearly for staff,
02:20people are aware of what the.
02:22Expectations are of them.
02:23They can access them,
02:25they can read and understand them.
02:26They can get their hands on
02:28the current version.
02:29Additionally,
02:30in a patient safety environment,
02:32my background was in a hospital environment.
02:35And you can imagine that ensuring
02:37people are following the most current,
02:40most accurate procedure can be very
02:42critical in terms of patient safety.
02:45It also is similar for
02:46employee accountability.
02:47Just speaking to what you can
02:49hold people accountable for.
02:50People need to know how and
02:53why they have to do something,
02:55and they need to be able to ensure
02:57that they're referencing the
02:58most current version available.
03:00And then if you do have good
03:03document management and control.
03:04That can just overall lower your
03:07risk of litigation and exposure
03:10in general and prior state.
03:12When I arrived at Yale,
03:14I think I was particularly
03:15sensitive to this because I was new.
03:18And what I find at Yale is for
03:20people who have been here for,
03:21you know, 15 years,
03:2320 years,
03:23a lot of you know how to find
03:25things or know where things are.
03:27But if you're new and you
03:29don't have that knowledge,
03:30it can be a little overwhelming.
03:32And the documents when I first arrived.
03:35Were definitely all over.
03:36They were all on different
03:38websites and you'd find one.
03:40And I find myself trying to save
03:42that to favorites because I wasn't
03:44sure how I got there and certainly
03:46wasn't sure if I could get back to it.
03:48I noticed that they didn't
03:51have standardized formats.
03:52There wasn't a consistent review cycle.
03:55We weren't ensuring that
03:56each document was reviewed,
03:58either on an annual basis or every few years.
04:01As mentioned, you couldn't find her access.
04:04Document awareness and some of the
04:06investigations that I was working on,
04:08I would often hear,
04:09oh,
04:09I didn't even know that that
04:11document existed or I didn't
04:13know where that policy was.
04:14There were conflicting
04:16and duplicate versions.
04:17I'd go to one site and
04:18maybe find the 1st 3 pages,
04:20and then on another site I'd find that,
04:22you know, the page.
04:23The document actually had 9 pages
04:25and so which one was the one
04:27that I should be referencing?
04:29And then in a more mature program,
04:31not only do you have them
04:32controlled and kind of standardized,
04:35but then you get into the
04:36content and the quality.
04:38How are they written?
04:38You know, are they grammatically clear?
04:41What's the wording,
04:42the level of reading?
04:43Can everyone understand what
04:45you're trying to convey?
04:46And then document category issues?
04:48I found that people were
04:50calling things different terms,
04:52and maybe they were meaning the same thing,
04:54but we had Daming conventions all over.
04:58So when this started,
04:59when I started my boss R and I'm asked
05:02if I would be willing to help with
05:04the project and because I love dot
05:06control and compliance in general,
05:08I thought yes, of course this will be fun.
05:10But this was a team approach.
05:12This took all of these individuals
05:15meeting multiple times.
05:16We met weekly,
05:17we had additional side meetings
05:19to really put together a plan of
05:22how we're going to approach it,
05:24what tool we wanted to select,
05:26what processes we wanted to put in place.
05:28And so all of these individuals really
05:31lent their time to the overall project.
05:33And what we landed on is we recognize
05:36the university had a document process,
05:39they have standardized templates.
05:41We are all subject to their
05:43policy and procedures.
05:45And so we thought,
05:45well,
05:46why don't we look at university
05:47and see what they have in place
05:49and then we can adopt pieces that
05:51work for the School of Medicine,
05:53but we also have flexibility of figuring out.
05:56Maybe what things would work for us
05:58that we wanted to do on our own.
06:00And so from the university level perspective,
06:03we realized we did want to align
06:05with their approval process.
06:06We like that they had a governance structure.
06:08They had a committee in place that
06:12had the right stakeholders at the
06:14table to review documents and approve them.
06:17We thought that it was important as
06:20we develop our policies to ensure
06:22we weren't just reduplicating
06:24a university level policy like
06:26we're already subject to those.
06:28So we wanted to make sure if we're
06:30having a School of Medicine policy,
06:33it was really necessary.
06:34It could be more restrictive,
06:36but it couldn't be less restrictive
06:39than university level.
06:40But we wanted to align with,
06:41as we develop our documents,
06:43ensuring it wasn't duplicate duplicative
06:45from what university was doing.
06:47And then we liked their template.
06:48We thought that the template that they had,
06:50the structure, the layout,
06:51the terminology was user friendly and
06:53had all the really key elements that
06:55we'd like to see in our documents.
06:57We decided to adopt their template
06:59and then for YSM.
07:01We do have some enhancements that
07:03the university doesn't yet have
07:06our tool because we went
07:07with navix and policy tech.
07:09It allows you to search and
07:11drill down into documents,
07:12which I'll show you so you no
07:14longer have to rely just on Google.
07:17You can actually use keyword search
07:19functionality to find documents,
07:21and that's really an enhancement.
07:24The improvement on review
07:26and approval process.
07:27The university has a little bit of
07:29a more restrictive review process
07:31and having to post things publicly
07:33for a certain period of time.
07:35We opted not to.
07:36We opted to not have one governance
07:38committee for all the documents
07:40because at the school we identified
07:42different buckets and groups
07:44that it wouldn't make sense to
07:46have one governance structure.
07:48So each area has their own committee.
07:51We altered that approach.
07:52And then we decided to differ
07:54on our review cycle.
07:55The university has a five year review cycle,
07:58but because our program really isn't
08:00as mature yet and we need to fine tune
08:03and clean up some of the documents,
08:05we opted for a three-year.
08:07So some some areas are doing one year,
08:10but the longest that they can go between
08:14reviewing and approving a document
08:16is 3 years and then naming conventions.
08:18So as I mentioned people were calling things.
08:21All different terms.
08:22And so we realized, okay,
08:24we need to really align
08:26on what these terms are,
08:28give them a definition and start to
08:30formalize that across the school.
08:32And so where we landed were policy.
08:35A policy really is a rule.
08:36This is a must.
08:38It's something that you should be held
08:40accountable to and you have to follow.
08:43An SOP process a procedure.
08:46This is really how to do something.
08:48It should be a stepbystep,
08:49clear,
08:50structured document that people
08:52can follow and understand how
08:54they operationalize a process.
08:56Guidelines or something that
08:59are best practices.
09:00They could be recommendations,
09:02but they really are optional.
09:04Technically, they should be held.
09:06You shouldn't be held accountable to them
09:08in the same way that you would a policy.
09:10This one will be a culture shift for
09:13the school and we're not there yet.
09:16What we realized is that would
09:17start by defining the documents
09:19in these terms to the best of our
09:21ability and get them in the tool
09:23and then as we get more awareness
09:25and education on the terms.
09:27And the documents come up for review.
09:29That's when I think we'll
09:30really start to clean them up.
09:32And you'll start seeing things fall
09:34more clearly into these definitions,
09:37bylaws or governance documents.
09:39Those are all then the tool forms.
09:42Forms is obvious,
09:43it's form and then reference materials.
09:45I will say for forms and reference materials,
09:48these aren't.
09:50We we want to avoid having navix become
09:53a or policy tech become a shared drive.
09:56So if it is a form and a reference
09:59material that has the need,
10:00it's a Yale School of Medicine
10:02specific document and it has a
10:04need to be controlled and reviewed
10:06on a regular basis and it ties
10:09to AYSM policy or procedure,
10:11then it makes sense to be dot controlled.
10:13Otherwise it would be something that
10:16would likely just live within the
10:18department or in your own drive.
10:20So here is a view of the template that
10:23I mentioned and we are Mary University
10:26and you can see here at the top, this
10:29really is what I mean by document control.
10:32So it's going to identify clearly
10:34to the user when you open it.
10:36You think, okay,
10:37this is a Yale School of Medicine document,
10:39here's the title.
10:40And then here are all the individuals
10:42involved in the document.
10:43You know what is the responsible
10:46area official policy sponsor.
10:48You'll hear that term.
10:49That is likely the person that was
10:51involved in writing the document and
10:53would be a subject matter expert.
10:55You have a doc administrator.
10:57This is an individual that is
10:59responsible for managing the document.
11:00They may not be the subject matter expert,
11:03but they are someone you could go to
11:05with questions and they can get you in
11:07touch with the person that can answer them.
11:09And then you can always see which
11:11you know when the date of origin,
11:12when was the document originally created,
11:15when was it last approved,
11:17and when was it last posted.
11:19And that helps you understand if
11:20this is the most current version,
11:23but another comfort is knowing
11:24if you're accessing it in navix,
11:26it is the most current version
11:28it's housed there for that reason.
11:30So this is really the layout that
11:31we like in the structure and all the
11:34documents are moving towards this.
11:35There were some that launch just have
11:38top part and then over time the rest
11:40of the document will align but they
11:43all have that core component at the
11:45top and over time they will match the
11:49full templates, document groups so.
11:51When we started,
11:53we knew this is this is very much an
11:55evolving project and that's why it's
11:57like I wanted to show you where we started,
12:00where we are today.
12:01And then now it becomes something that really
12:03is fluid and breathing with the community.
12:05Because by showing you and having you
12:08experience the tool and giving us feedback,
12:10we're going to make it better and it's
12:12going to grow from this point forward.
12:14But what we started with was what are
12:17the largest group of documents we know
12:19right now are public facing and let's.
12:22Put our arms around those and then as
12:24there becomes more awareness of the tool,
12:26I'm sure other areas in the school
12:27are going to want to leverage
12:29it and we'll expand from there.
12:30So it's not that this is the
12:32only group of documents,
12:33but this is where we had to start governance.
12:36That's all different bylaws.
12:39Faculty,
12:39this is a area that will house any
12:41of the policy and procedures that
12:44relate to faculty so that they
12:46can easily navigate them.
12:48OAPD,
12:48academic faculty affairs policy and
12:50procedures, they will be added to this.
12:52They're not there yet.
12:53We still are working with them
12:55to get their documents templated,
12:56but they will be housed in that grouping.
12:59Education this is has all of the
13:02empty education documents and then
13:04over time we bringing in PA&amp;MHS.
13:06Research YCCI will have all of their SOP's,
13:10their procedures placed in the tool and then
13:12we'll move from there and then clinical.
13:14That's where you're going to find any
13:16of the Yale Medicine administration
13:18documents and the Yale Medicine practice
13:20standards and then of course finance
13:22and administration and communications.
13:24And I'm going to actually show
13:27you in the tool do this,
13:32OK. So this is the actual
13:35website that is now live.
13:36And the group put a lot of thought
13:38into this because one of the challenges
13:40that we had was we knew you have to
13:43navigate a lot of documents that aren't
13:45all owned by Yale School of Medicine.
13:47You have to frequent documents
13:49that are university level.
13:50So we thought,
13:51how do we solve for that problem?
13:53And we approached it.
13:54They use the term wayfinding.
13:56And when I say that it's,
13:58it's similar to when you're in an airport
13:59and you have to find your way to a gate.
14:01You've never been to the airport before.
14:03But you have to get to your plane.
14:05With good signage and good navigation,
14:07you can help someone get
14:08to where they need to go.
14:09And so we group the documents
14:11by anything here is going to be
14:13in the portal that I mentioned.
14:15These are going to be Yale School
14:17of Medicine specific documents,
14:19but you may also need to go to the
14:22university level documents which you
14:24have to still follow or research.
14:26Office of Provost,
14:27things like Faculty Handbook and then
14:29some individuals have to go to Yale
14:31New Haven health policy and procedures.
14:33So that's kind of the layout.
14:35As I mentioned,
14:36OAPD documents are not housed yet
14:38in the tool and so we are going
14:41to be inserting a placeholder
14:43here for individuals that need to
14:45get to the OAPD process.
14:47And then over time the items
14:49that are YSM are going to be
14:51incorporated into the tool,
14:52but we'll go ahead and go in.
14:58And you can see once you're in the tool
15:00you have two searching options and
15:03there are help manuals I'll show you.
15:05They live in two places that are going
15:07to give you screenshots of all of this.
15:10But when you first enter into
15:11the tool you have two options.
15:13You could search, which I'll show you after,
15:16and browse is what it defaults to.
15:18Browse shows you all of the category
15:21documents here and in this about policy tech.
15:24Is where you're going to find
15:26some helpful manuals.
15:27And these manuals can be for a general user.
15:29You just want to know how do I
15:31search for a document or if you
15:33have the functionality where you
15:34are actually someone who drafts
15:36documents or has to approve.
15:38These are more technical on kind of
15:40the back end navigation of the tool.
15:43Then you can go into all
15:44documents and you say, okay,
15:46I want to look at everything
15:47that we have at YSM.
15:49This is going to give you a full list.
15:51If you want to search,
15:53you're like,
15:53I need to look at that thing.
15:54I think it's called budget something
15:57you can put budget in click and
16:00that is searching through all of the
16:03documents we have and going to pull up
16:05anything that has budget either in the
16:08title or somewhere in the document itself.
16:10So that's what I mean by a keyword.
16:13Now interesting thing with keywords is that.
16:17We can make the tool more
16:19sophisticated over time.
16:20So if you call something,
16:22if you are,
16:23you know,
16:24individuals refer to a document in a
16:26different way than it's named or have
16:28some sort of term that you've entered
16:31in four times and nothing's coming up,
16:34give that information to parmi,
16:35e-mail that to parmi,
16:36because we can add it in the back end and
16:39it will enhance the search moving forward.
16:42And an example of that in my
16:44prior life was privacy policies.
16:45So anything related to HIPAA.
16:48HIPAA,
16:48a lot of people spell wrong
16:50and so you wouldn't have HIPAA
16:52spelled incorrectly in your title,
16:54and hopefully you don't have HIPAA
16:55spelled incorrectly in your policy,
16:57but you're searching for it.
16:59You'd think, okay,
16:59a lot of people are going to misspell that.
17:01I'm going to use that as a keyword.
17:02So even if they do enter it incorrectly,
17:04it's still going to pull up all
17:06of the HIPAA policies.
17:08So just keep that in mind if it's
17:09something that you refer to,
17:10because we can continue to enhance
17:12kind of the search functionality.
17:14But this word is going to search
17:17everything within this folder.
17:18And that's an important take away too,
17:20because when you go down into,
17:22say, governance and you want,
17:24I mean this is easy because you
17:26can see all of them.
17:27But if you wanted to do some sort of search,
17:29we'll do it in here where there's more.
17:32If you wanted to search for the policies
17:35within finance and administration,
17:37if I type in the word budget here,
17:40it is only searching within that folder.
17:43And so if you wanted to search all
17:46the documents, you have to remember
17:48I need to go to all the documents,
17:50otherwise you're just searching
17:52within the folder itself.
17:54Each of these have the ability to.
17:57I'm going to get rid of
17:59that keyword to expand.
18:01And they are further kind of sub
18:04categorized and broken down here
18:06you can see the clinical goes to YM
18:09administration and practice standards.
18:11And then another search option
18:13that some people like are,
18:14well I actually want to see all
18:17the documents that are a policy
18:20for YSM and this is going to be
18:21a mixture of any of these items,
18:23but it's all the policies are
18:24all the procedures.
18:25So it allows you to search
18:26in a lot of different ways.
18:28And then if you don't like this,
18:30you could also just come in,
18:32click on search,
18:33and you can type in the word here.
18:36And this is similar to the search
18:38functionality that I just did,
18:39where it searched all documents.
18:41You click on it and it's going to
18:43display all of the documents there.
18:44So lots of different ways that
18:46you can search.
18:47And if at any point you have questions,
18:49again, hermie's here to help.
18:51We're here to help.
18:53So you're never alone in navigating this.
18:56The other thing that I wanted to
18:58show you is here policy tech help.
19:02So in addition in the tool where
19:03you can see those manuals,
19:05This site is a lot of information
19:07on policy tech as well.
19:09So it's going to tell you what it does,
19:11how to open.
19:12If you go in here, these are the manuals.
19:14How do I search for things.
19:16We're going to put this video
19:17up and other videos.
19:19So there's a lot of material here to help
19:22you navigate and maximize the tool itself.
19:26And now see if I can go back here.
19:36We just went through navigation so.
19:38This, this presentation is really
19:40geared at the front end user
19:42experience for individuals that I
19:44need to find that policy and what is
19:46the easiest way for me to do that.
19:48But I do want to highlight that the
19:50tool brings a lot of enhancements on
19:53what I call the back end experience
19:55as well and that ties to more of
19:57the document management process.
19:59So if you are an individual that authors
20:02policy or procedures or has to approve.
20:06The tool has this functionality
20:08where it's managing the document.
20:10So it's going to send reminders
20:11to individuals.
20:12When your document is up for renewal,
20:15if it hasn't been reviewed and
20:16you've said it to be reviewed,
20:17let's say every 12 months,
20:19it's going to e-mail you and let you know,
20:21oh, I have to review this.
20:22And then when you review the document,
20:24it's going to move the document
20:27through the review process.
20:29From the writers to the reviewers,
20:31and we no longer have to have,
20:34you know,
20:34word documents attached to emails sent out,
20:37where then you're trying to consolidate
20:395 different emails with a lot of
20:41different red lines and people are
20:42responding in e-mail versus in the document.
20:44All that goes away where we're
20:46able to work on one document in the
20:48tool and it will move through the
20:50individuals necessary for developing it.
20:52So that will be a great enhancement and
20:55then from a compliance perspective.
20:58The tool also tracks and reports
21:00the whole history of the document.
21:02So once a document is created in the tool,
21:05you know five years from now you
21:07could print out a report and you'd be
21:09able to see when was this originated,
21:11who were the individuals involved
21:13in creating the document each time
21:15it was reviewed and revised,
21:16what revisions took place?
21:18You have a way to track and really
21:20see the life cycle of the document,
21:22which can be important in different
21:26scenarios and situations.
21:28Make it over here
21:31so some key contacts for people that I think
21:34are important for individuals to know and
21:37this information is on the website itself.
21:41This up here is the generic e-mail that
21:44we created and parmi will put this in the
21:46chat so everyone can have that as well.
21:48But this is where if you
21:49have a general question,
21:50if you're trying to find a document
21:52or you want to create a document,
21:53you can e-mail here and parmi will respond.
21:56Each of the areas that I mentioned for groups
21:59of documents have a document administrator.
22:02And again, that person doesn't
22:04necessarily draft the documents,
22:05but they are responsible for managing them.
22:08And you can reach out to them and they
22:10can help you kind of navigate and find
22:12the policy or procedure that you need
22:13to or answer questions and get you in
22:16contact with the subject matter experts.
22:19And we're going to add additional DOC admins
22:22over time as the groups themselves evolve.
22:25With that, I'm going to stop
22:30and open for questions.
22:40See
22:45does anyone have any questions.
22:47If you have questions,
22:47you can put them in the chat,
22:48you can take yourself off mute and.
22:52Talk or if you don't have
22:53questions for the group,
22:54but you have questions as soon as
22:56you close this or a week from now,
22:57we're happy to answer those as well.
23:00You can always reach out to us directly.
23:04Thank you for this.
23:05This is very thorough.
23:06It's very helpful. Oh, good.
23:10I agree. This is great that
23:12we have something like this.
23:16So it's just been like when
23:18you're trying to. Find something.
23:19You're like, where do I go?
23:20Who do I ask? So this is nice.
23:22This is a great thing you created.
23:24Thank you, thank you.
23:27We're all, we are all
23:29really excited about it.
23:30But we're also humble and knowing
23:31that it's a starting point.
23:33So as you actually use it,
23:35please give us feedback.
23:37That's where I think we can really
23:39make it something special for everyone.
23:43Yeah, I'll just, I'll just add to
23:45that Andrea that you know as we as
23:47we think about our processes and
23:49how we implement things at Yale
23:50where I think sometimes we're taking
23:52a different approach now, right.
23:54And we're we're doing things at a
23:58quicker pace and putting something out
24:00there for people to respond and to react to,
24:02but also to use in the in the interim,
24:04right, rather than waiting
24:07until everything's perfect.
24:08So please this is a a living and breathing.
24:13Kind of process and it will get better
24:16the more input that we get you know
24:19the more the more keywords that we
24:21can provide to par me and and and
24:24the more we use this and and give
24:26feedback on you know this doesn't feel
24:28like it's quite in the right spot or
24:30you know so please engage with it.
24:32It's going to be a helpful tool
24:34for all of us.
24:35Nice nice job par me and
24:37and Andrea it's great.
24:38Thank you. Thank you.
24:47Okay. Well, we'll give you back some time.
24:49Thank you all for coming.
24:50This has been like overwhelming
24:52and wonderful to see how many
24:53people show up with interest
24:55and insight into the project.
24:56So we appreciate your time. Thank you.