Managing Policies, Procedures and Guidelines Policies, Procedures and Guidelines Project Group
Project Planning What are we trying to accomplish? Greater engagement of library services in the management of organisational policies, procedures and guidelines How will we know that change is an improvement? Submission of impact case studies around policies, procedures and guidelines What change can we make that will result in improvement? Provide librarians with ideas and support to implement within their own organisation
Project Outline “ boundaries (i.e. STP footprints)” ” Investigate and produce good practice guidance for library and knowledge team involvement in managing policies and procedures*, particularly facilitating access across organisational Also to scope, trial, and devise lessons learned around the development of a cross-organisation, system-wide policy and procedure management process * Extended to include guidelines
Shared purpose statement “ To design and produce a resource for LKS services, sharing good practice and lessons learned in organising and disseminating evidence based internal policies, procedures and guidelines ” including across organisational boundaries by September 2017.
Task allocation Leadership by all ‘Buddy - up’ skills matrix for personal leadership development
What we did: Project & performance mgmt Project plan for effective management and timely deliverables
What we did: Define Agreed on shared purpose statement Benchmark Improvement Undertook a literature search of key databases on HDAS tools Hand-search of HLG conference papers and presentation (2008 to present) Presentations from ‘What’s new and the librarian’s role’ Guidelines Study Day held at Glenfield Hospital Leicester on 3 rd November 2015 Measure Created and sent out a survey via NHS Leads to LKS managers to ascertain current practice Followed up with interviews of those willing to be included as case studies
Outcomes Other 71 responses Public Health 19 responses for follow-ups Mental Health Local Authority (exc. PH staff) Measurement Learning Disability Community Trust Clinical Commissioning Group Acute 0 10 20 30 40 50 60 Not at all A little Somewhat To a great extent Review and maintain KM group to review impact cases Rerun survey in 2019
Summary of main findings Wide variation in involvement with management of PPGs From no involvement to full management LKS involvement characterised into 3 areas: Literature searching (1) Hosting /process management (2) Implementation /cultural shift (3)
Literature searching (1) Full literature/evidence search Some only when asked, others a compulsory part of the process Question the evidence base and quality Other services provided: Proof-reading and document corrections Reference checking Scoping searches Search skills training sessions
Case Study 1: Bridgewater Community Healthcare NHS Trust Full literature search carried out for each guideline Range of traditional and non-traditional sources used, depending on topic Based on latest available versions of national standards/guidelines Guidelines only approved once they have been checked by library Summary of main outcomes: Guidelines are evidence-based and current in relation to CQC requirements Raised the profile of the Library service within Trust Immediate impact - recent support for Medicines Management department on the production of a guideline on the use of fetanyl patches for pain relief in end of life care proved invaluable
Hosting/process management (2) Examples of involvement include: Librarian /LKS staff sit on relevant groups or panels Sending out update reminders when PPG nearing expiry Designing naming conventions for documents Tagging and meta data Maintaining and archiving policy repository Cataloguing of documents
Case Study 2:Derby Teaching Hospitals NHS Foundation Trust Ownership and management of the system for storing and accessing PPGs Koha system is used, which is available via the internet – accessible anywhere LKS now looks after the whole process Full participation in the Clinical Guidelines Group Summary of main outcomes: Improved access to policies and guidelines Improved consistency and version control Removed need for FOI requests as all on open access Full audit trail available if required Ultimately reduced risk to patients
Implementation/cultural shift (3) Working with policy leads To support sharing across organisational boundaries by using creative commons Use of SharePoint/other systems Increasing productivity and efficiencies through automation Clinical input Essential for successful implementation to occur
Case Study 3: Berkshire Healthcare NHS Foundation Trust No systematic process for LKS contributing to PPGs Support is provided in the form of undertaking literature searches on a request basis LKS also works with Policy leads and content specialists to develop interactive e-learning packages linked to the policies, for example, on antimicrobial guidelines, patient group directives and pressure ulcers Recommendation made Would be useful if authors used ‘creative commons’ to encourage cross -organisational working, particularly in light of STPs
Key benefits (1) Reduced risk and improved patient safety Influencing factors Improved currency of PPG Improved consistency, version control and ease of access Saves clinical staff time
Key benefits (2) Less confusion Influencing Easily accessible data for KPIs factors Built-in electronic audit trail Raises profile and value-added benefit of LKS
Main challenges PPG time consuming and lengthy process(es) Resulted in lower prioritisation Lack of LKS staff time to participate Conflicting priorities; limited resource and capacity Involvement inconsistency Clinical staff not always engaged
Plan of action Condense case studies into a ‘toolkit’ Contains examples of all levels of involvement Spread & Based on the premise that one size does not fit all adopt Contact details available in the toolkit Offer more support from those willing to offer further advice and information
Development proposals Further librarians engagement through: Regional presentations Motivate & Present at HLG mobilise Article in HLG newsletter Engage new stakeholders through: Involvement of clinical staff/other departments Cross organisational working
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