Gap Analysis - Genius Papers

Previous state

Policies were purged and Lippincott was implemented
This caused a huge dissatisfier for the staff and mostly new hires.
This left staff confused and feeling lost with basic standard of practices
Policies, Guidelines, SOPs and Lippincott are all located in different areas making it difficult for the staff to locate
Staff and management not understanding the difference between Policies, guideline, and SOP’s.

Current state

Below is where the hospital is currently at with policies, SOP, and guidelines.

Steps taken to get here
- Standardization of education across the hospital and ownership of policies
- Education to the education team and leaders on the difference of Policy vs SOP vs Guideline
- Education to the education tem on how to initiate and follow up on policies via compliance 360

This was completed by the Holtz Women’s and children’s education team

Current Policy revisions
- Pediatrics
  - Brain Death Determination Pedi—JHS 400.087.1
  - Parental or Guard Notification for Pts under 18 for Pregnancy—JHS 4000.013.1
  - Organ Donation After Cardiac Death Pedi—JHS 400.018.1
  - Disclosure of HIV Status to Minors—JHS 400.050
  - Exchange transfusion
  - Closed medication administration system

Women’s
- Fetal Reeducation—JHS 400.013.2
- Termination of Pregnancy—JHS 400.013
- Certificate of Fetal Death; Stillbirth Reg—JHS 400.011
- Sterilization—JHS 400.010
- Low Risk Delivery Newborn Resuscitation
- Baby Friendly breast feeding
- High risk delivery newborn resuscitation

Newly Established Policies
- VAD policy
- Oxytocin concentration
- PCN desensitization
- CRRT/ECHMO
- OB
  - OB patient disposition
  - OB patient care
- Pediatric Code Blue
- Neonatal Code Blue

Guidelines
- Unit Admission Guidelines
- Unit specific Documentation Guidelines
- Required task per shift (eg: IPOC)

Pathways
- Early onset sepsis
- Hypoglycemia
- Hyperbilirubinemia
- Code Pink

SOP’s
- Protocol for management of Placentas
- OB Alert Emergency Standard of Care
- MFTI
- Prioritization of the OB patient in triage

Quick tips
- IV site documentation
- Admission, Discharge, transfer criteria (referencing policy 401)
- Care and Maintenance of Vascular Access Devices
- Medication Administration (referencing policy 400.025)
- Berlin Heart

Resource Binders

The Education team has also been a part of the following system wide policies

Top 6policies requested from the survey (see attached)

Vascular access Device/Management/Dressing change

Unit Admission Guidelines—-Making a guideline

Documentation Guidelines—Making a Guideline

Thermoregulation (neonatal standard of practice)

Nursing standard of practice—-Addressed in the Unit admission and documentation guideline

Tracheostomy Care

Future

things that we are working on to ensure that resources are available for staff in a central location

Resource Binders
- front part of each binder will be standardized hospital wide (see below)
- Second half of each binder will have valid information and tools for each unit to assist with the following:
  - Documentation standards per unit
  - Quick tips
- We are working with IT to have the binders be electronic with links for easy access.

to be on the following units within Holtz and Women’s

Each binder to consist of the following

KEY

In progress

Recently completed

Requested, not initiated