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How an RN Accreditation Specialist undertook a journey to better policy management

Many a health care professional has told us it would be so helpful to hear from a peer who went from paper policies to policy management software in their organization. Thank you to Jean Sandrock of St. Luke’s Hospital in Maumee, Ohio, a hospital near Toledo, for sharing her experience of choosing a policy management software provider and implementing the software.

St. Luke's policy management software provider

In a webinar Jean presented for us, she talked about factors that made it clear her organization needed a change in terms of managing its documents, the assessment she and her colleagues performed of current systems and policies, the consideration process they went through to select a policy management software provider, getting buy-in from administrators, implementing the software, their follow-up process and lessons she learned throughout the whole process.


For a couple of reasons, it was obvious to Jean that St. Luke’s Hospital needed a change.

First, the hospital was involved in a Joinder agreement with a local system in 2010, and early on there was a challenge by a local union that the joinder would cause a monopoly on beds for Obstetrics.

For about 7 years, the case went through the legal and then appellate process. The case eventually was escalated up to the Supreme Court in Washington, D.C., for review. They chose not to hear the case, and the lower court’s decision to divest St. Luke’s from the system was upheld. On July 1, 2016, St. Luke’s became an independent hospital once more. The rebranding and change process began in earnest.

Second, as a DNV-GL Hospital, St Luke’s follows both the International Organization of Standards (IOS) and the National Integrated Accreditations for Health Care Organizations (NIAHO) standards. ISO standards talk about reduction of variation and control of documents and documented information (i.e. document control), so as RN Accreditation Specialist, Jean began the document control journey in February, 2016.


policy management software providerGenerations of policies had one thing in common, and that was control issues. Original policies at St. Luke’s started in three ring binders, and next generation of policies were electronic in a home grown system. Upon review of about 1,500 existing policies, Jean and her team found many issues, for example:

  • Four different headers from different people who were processing
  • Departments that were using only corporate policies either had none now that the hospital was independent or needed to convert
  • Approval processes were missing

The assessment showed what Jean expected, so she was ready to begin searching for a policy management system provider.


Jean convened a policy committee that consisted of members who could make decisions. The team reviewed five different policy system products currently on the market, then held back-to-back comparative demonstrations on the team’s top two choices.

After discussing the pros and cons of both choices, the policy team unanimously chose PolicyStat.


The team had one more step to undertake before it could start implementing the software. First, team members made the request to administration. Their ace in the hole? The VP of Patient Care Services / CNO was an active member of the policy team. That meant they had the support they needed to make the administration heed their recommendation.

As soon as they received administrative approval, the team completed its contract with PolicyStat, and St. Luke’s was ready to start the implementation process and get organized.


PolicyStat assigned a Project Manager to St. Luke’s, and the change process began. Jean knew she had about 1,500 policies from old electronic records and had to figure out how to systematically address such a high volume. The policy team needed to establish how members wanted the system to work. It took a while and a little frustration, but the team finally got to a place where the vision was being implemented.

Jean printed electronic file copies of existing policies and sent them off to each manager. The policy team developed a form for the manager to sign off on for any changes that were needed.

policy management software providerThe team hosted several “policy parties” in the St. Luke’s auditorium, where managers could work on revisions without interruptions. Snacks helped! The parties were highly and surprisingly successful and allowed them to determine whether to revise, delete or make no changes to policies (other than adding the date).

It took Jean and the team a while to figure out how to set up bucket lists, but in the end they chose:

  • ORG (any area that serviced the entire hospital) policies and work instructions
  • MS (Medical Staff) policies
  • PCS (all Patient Care Services) policies and work instructions
  • SS (all Support Services) policies and work instructions
  • WC (WellCare – contracted physician practices)

Due to the large volume of policies it was converting, the St. Luke’s team chose to assign owners and approvers as a second step. In hindsight, they decided they should have entered on the first go-round with the buckets.

With manager revisions being completed on paper copies, the team needed resources for typing. St. Luke’s established four support coordinators to manage the buckets and support the various units and areas. Later, they added a fifth coordinator to support WellCare.

In fact, the need for typing resources escalated to administration, which granted approval to pull coordinators from normal duties one to two days each week to revise and upload policies. The team used additional typing resources whenever available. Jean hypothesized that because the St. Luke’s policy process was “broken,” it took more resources than an implementation would for a facility that started with a more intact process.


Once all IT logistics had been resolved and the majority of policies had been uploaded, accepted and converted, it was time to go live with PolicyStat. The policy team made educational rounds for the days before and after St. Luke’s went live with PolicyStat, and staff caught on quickly how to access and search within the software.

policy management software providerAs St. Luke’s had had an accreditation visit finding the previous year on document control, the survey team highlighted PolicyStat and the success story from St. Luke’s on the accreditation surveyor’s next visit.

Today, Jean estimates that St. Luke’s has more than 2,100 policies or work instructions in PolicyStat. In the one year since implementation, her team has added departments and policies that were missing post-divestiture.

She and the team recently revised all 75+ departmental scope of service documents in a new template format. This time, managers and senior leaders are approving them electronically. The team sent a Survey Monkey survey to assess staff knowledge after implementation and found that targeted education had resulted.

According to Jean, electronic management is the way to go. With it, there are no more paper policies floating from person to person, waiting for changes, getting lost, etc. Tracking is available to help push your leaders and processes.


Post-implementation, a review by St. Luke’s yielded opportunities and positive results of PolicyStat.

The opportunities were:

  • More direction in the early phase (i.e. knowing where to start)
  • Seeing an example from another client to see what the end product looked like and their story
  • A few specific features in the editing process that could be a little easier to maneuver through
  • Template limitations – uses HTML formatting and allows only one header logo across all documents

Positives included:

  • Weekly conference calls to work through any issues
  • Tutorials available within the system
  • Easy to use; staff love the system

If you’d like to hear Jean talk through her story, you can listen to the webinar.

Was there any part of Jean and St. Luke’s journey that you wouldn’t have considered when starting with a policy management software provider? What did you learn in your journey to better document control? Tell us on our Facebook page.

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