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Oct 26, 2022 321 likes •532 views

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

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Managing Policies, Procedures and Guidelines

Policies, Procedures and Guidelines Project Group

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Project Planning

What are we trying to accomplish?

Greater engagement of library services in the management of

rganisational 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

rganisation

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Project Outline

Also to scope, trial, and devise lessons learned around the development of a cross-organisation, system-wide policy and procedure management process

“

Investigate and produce good practice guidance for library and knowledge team involvement in managing policies and procedures*, particularly facilitating access across organisational boundaries (i.e. STP footprints)” ”

* Extended to include guidelines

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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.

“ ”

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Task allocation

Leadership by all

‘Buddy-up’ skills matrix for personal leadership development

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What we did:

Project & performance mgmt

Project plan for effective management and timely deliverables

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What we did:

Define

Agreed on shared purpose statement

Benchmark

Undertook a literature search of key databases on HDAS 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 3rd 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

Improvement tools

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Outcomes

Measurement

10 20 30 40 50 60 Acute Clinical Commissioning Group Community Trust Learning Disability Local Authority (exc. PH staff) Mental Health Public Health Other Not at all A little Somewhat To a great extent 71 responses 19 responses for follow-ups

Review and maintain

KM group to review impact cases Rerun survey in 2019

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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)

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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

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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

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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

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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

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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

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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

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Key benefits (1)

Reduced risk and improved patient safety Improved currency of PPG Improved consistency, version control and ease of access Saves clinical staff time

Influencing factors

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Key benefits (2)

Less confusion Easily accessible data for KPIs Built-in electronic audit trail Raises profile and value-added benefit of LKS

Influencing factors

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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

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Plan of action

Condense case studies into a ‘toolkit’

Contains examples of all levels of involvement Based on the premise that one size does not fit all

Contact details available in the toolkit

Offer more support from those willing to offer further advice and information

Spread & adopt

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Development proposals

Motivate & mobilise Further librarians engagement through:

Regional presentations Present at HLG Article in HLG newsletter

Engage new stakeholders through:

Involvement of clinical staff/other departments Cross organisational working