Converting an Academic Medical Center to NIAHO/ISO 9001: CAMC Case Study

Converting an Academic Medical Center to NIAHO/ISO 9001: CAMC Case Study


Converting an Academic Medical Center to NIAHO/ISO 9001

Dr. Glen Crotty, Vicky Grate & Wes Chapman

September 29th, 2014

This is the first in a series looking at the motivations, methods and outcomes from our efforts at Charleston Area Medical Center (CAMC) to build a “best-in-class” patient centered quality management system (QMS) including accreditation via NIAHO/ISO 9001. These articles are designed to be quick reads, and capture the realities that we encountered in this quest.

Buried in Documents

Buried in Documents

Identifying the Fundamental Problem

It began with two simple questions – how many policies and procedures do you have, and do you actually train to them? These were both fair questions, were impossible to answer when we started working together, and launched a major effort to streamline, simplify and make useful the policies and procedures that defined all of the important aspects of care delivery and interaction at Charleston Area Medical Center (CAMC).

CAMC – Background

Charleston Area Medical Center is a nonprofit, 908-bed, regional referral and academic medical center with more than 6,000 employees. CAMC is made up of four hospitals and is home to one of the largest heart programs in the United States; the only kidney transplant center in West Virginia; the highest level trauma center; and the only freestanding children’s hospital in the state. All medical services are supported by primary care physicians throughout the region who regularly treat their patients at CAMC hospitals or refer them to CAMC for specialty consultation and treatment.

Like most large academic medical centers in the US, CAMC has been accredited through The Joint Commission (TJC) and its predecessors since those organizations were given accreditation power by CMS back in the 1960’s. Unlike many other centers, however, CAMC has had a long-term commitment to the implementation and use of lean and six sigma (LSS) process improvement tools and systems (for the last 8-10 years), and for the last 4-5 years has made a major commitment to the Baldrige Criteria for Performance Excellence (Baldrige).

Tying together all of these quality efforts, we set the following high level goals for our entire organization as part of our Baldrige efforts:

1) Best usage of our resources and elimination of waste,

2) A culture of employee involvement and engagement in solving problems and making  improvements,

3) Organized, efficient work areas that are maintained using visual management,

4) Standardized “best practice” processes to deliver consistent, top quality results, and

5) Increased satisfaction for staff, patients, and families.


Building an Efficient and Effective Quality System

From CAMC’s perspective, we built a three legged stool supporting our fundamental goal of patient centered, clinical quality improvement: 1) TJC, controlling clinical operations, documentation and training, 2) LSS, controlling process improvement, and 3) Baldrige, ensuring integration of strategy and resources with continuous improvement.



Three Legged Stool Supporting Quality

The combination of LSS and Baldrige proved to be an effective platform for quality development, and CAMC benefitted with continuous improvement in a broad spectrum of quality improvement metrics, including Meaningful Use, the Value Based Purchasing initiative through CMS and a broad spectrum of clinically specific accreditations and certifications. Increasingly, however, the written process documentation – termed policies and procedures (P&Ps) – required by TJC were proving to be material limitations on quality improvement.

We had documented a large number of clinical processes in a modern hierarchical system in our EMR and through our LSS efforts. At CAMC, written process maps, and documented procedures are critical components of medical care. Process maps and procedural documentation define “best practices” and how care will be delivered in any clinical setting. This is critical to ensure consistent patient care, and to facilitate efficient team work – minimizing waste. Policies are guidance statements defining what we do and why we do it.


In most areas however, we were still dominated by a large, and clumsy set of P&Ps. As used historically, P&Ps are an archaic construct, designed decades ago when medicine involved vastly fewer procedures, offered fewer imaging and diagnostic tests, and the determination of best practices was much less structured and timely. Additionally, computerized document control and retrieval systems did not exist, and all documentation was maintained in departmental manuals to facilitate ease of access. As care delivery systems became more complex, so did the documents to define and support them – by 2013 we had a byzantine construct of over 150 manuals and P&Ps numbering in the thousands.

 Tied up in knots

Tied up in knots by archaic documents


Over the years, efforts to comply with the quality operating requirements of TJC resulted in first more P&Ps, and then more manuals, and then both. The documents were inconsistent in design and structure, impossibly long and complicated, redundant, contradictory and extremely difficult to comply with, train to and maintain. The document system itself had become a major obstacle to efficient operation, quality care delivery and continuous improvement. Something had to change. We needed to simplify.

simplicity flowchart

Simplicity is the Ultimate Sophistication

Leonardo da Vinci


Planning for Change


We set out with a simple project plan – filter the P&Ps in administration and nursing using 7-8 practical filters designed to determine need (looking at redundancy, contradictions etc.), rank P&Ps according to risk according to 12 predetermined criteria, and then evaluate their disposition. Using the pilot project as a “learning lab” then move forward based on what we had learned, and what seemed to work.


In broad terms we set simple goals – reduce P&Ps by at least 25%, reduce total words by at least 50%, and use third party best practices where ever possible – such as the electronic version of Lippincott’s Nursing Procedures. Finally, we set as an overall goal of having a set of P&Ps capable of passing a “desktop audit within 12 months of starting the project.


Within the first six months we have “filtered and risk adjusted” all of our old P&Ps, and earmarked well over 50% for retirement – through elimination, consolidation, and replacement by third party standards. We are implementing a novel document maintenance, search and retrieval system using a proprietary relational data base structure. This has allowed us to maintain a good audit trail regarding document transitioning and retirement. We appear to be well ahead of our initial goals of document reduction, and our simplification efforts should dramatically improve document utility and value for training.


This has been much more intensive of senior management time then we had originally anticipated, and this was the most noteworthy deviation from our original plan. This has proven to be quite valuable, however, as the resulting simplicity should dramatically improve reporting and shorten communication times. Anyway, that is what we are aiming for.


In the next article we will look more deeply at methods we are using, and surprises along the way – and there have been quite a few.

Wes Chapman
Written by Wes Chapman

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