Policy and Procedure Management Support for Tipperary University Hospital

Healthcare professionals in a team meeting undertaking process mapping.

“The collaboration between HCI’s Best Practice and Digital Transformation Teams enabled a thorough review and update of documents, ensuring duplicate documents were removed, permissions correctly configured, and ownership clearly assigned in the QMIS. The Best Practice Team also provided a detailed report that serves as a roadmap for aligning our documents with national guidelines. Having HCI’s expertise has given us confidence in the quality of this review, saved us considerable time, and reduced pressure on internal resources. This project has been invaluable in strengthening our documentation and supporting our commitment to patient safety.”

Maria Barry

Hospital Manager, Tipperary University Hospital

Background

Tipperary University Hospital (TippUH), is an acute hospital providing medical, surgical, obstetrics and paediatric care.

Recognising the essential role of well-managed policies and procedures, TippUH engaged HCI’s expertise in policy and procedure management to support its compliance and quality improvement goals. This initiative leveraged HCI’s strengths in digital transformation and best practice management to update and streamline document governance on the Quality Management Information System (QMIS), aligning with the hospital’s stringent policy framework.

Objectives

Review 75 External National Documents and 39 Leaflets, cross-referencing them with internal policies for alignment.
Provide recommendations for areas for update and development within the internal policies.
Compare Maternity documents against the ISWID database.
Remove duplicates, review document permissions and assign ownership to unassigned documents on the QMIS.
Update the QMIS with the required changes.

Solution

HCI employed a collaborative, phased approach that integrated the expertise of both our Best Practice and Digital Transformation Teams. Our solution involved:

Development of project plan.

Review of External National Documents and Leaflets.

Cross reference with TippUH’s internal Policies and Procedures.

Develop Report identifying areas for update.

Compare maternity documents against ISWID database.

Review document permissions on the QMIS.

Review internal documents with no ownership and recommend allocations.

Develop Report on document updates to be made on the QMIS.

Update documents on the QMIS as agreed with the client.

Key Statistics

75 External National Documents reviewed by best practice.
39 External Leaflets reviewed by best practice.
77 Maternity documents compared against the ISWID database.

Outcome

Upon completion, the quality of the document records available on TippUH’s QMIS system has significantly improved. A thorough review of internal documents, removal of duplicates, and optimisation of the QMIS settings, has facilitated better access control and ownership of documents. In addition to the updated records, TippUH also received further recommendations in relation to the required updates to documents to align with national documents.

The collaborative approach between HCI’s Digital Transformation and Best Practice Teams has ensured that TippUH received a comprehensive review and update of their documents.

Benefits

Comprehensive and independent review of documents by HCI’s best practice and digital transformation specialists.
Clear roadmap with recommendations of where policies need to be updated to align with national documents.
Saves time and reduces pressure on internal resources in updating documents.
Improves the quality of records available on the QMIS.
The update of the system has resulted in an increase in staff utilisation of the QMIS.
Supports regulatory compliance.
Ensure staff are following up to date policies, supporting patient safety.
Assigning ownership to documents ensures that documents will be reviewed and updated as required.
Provides reassurances to the Management Team about the quality of the documents in the QMIS.