Codification Kick-off Meeting Standard Operating Procedures December 4, 2013

SOP PIG Exercise

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SOP PIG Exercise

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SOP PIG Exercise

Lunch

Codification Kick-off Agenda

• • • • • • • • Introductions/PIG Exercise Lunch Background/Need Codification Charge/Deliverables Timeline Project Roles/Structure Planning and Project Management Next Steps

IS CODIFICATION NECESSARY?

Background

• • • Dr. Azziz called for the codification of all standardized operating procedures (SOPs) The codification process was complicated by the demands of consolidation Under the leadership of the Compliance/Legal Team, the Enterprise Codification Process will become a part of our team effort to develop standard operating procedures across the Enterprise

Need for Codification

• • To ensure the internal business consistency of unit operations and continuity in delivery for vital services in the event of a major disruption in services or unanticipated change in leadership To ensure consistency of information and communication of the service and process functions of the enterprise – To address the lack of an enterprise-wide catalogue of services that hinders institutional consolidation and transition management efforts

How do I?

• •

External Customer

What processes do you have that deal with outward facing customers Outside facing customers can include other units within the enterprise •

Employees

What processes do you have that have only an internal impact within your unit • Ex.: Management of an outside audit • Ex.: Triage process for a Hotline call

These are the processes that need to standardized and codified!

Terms/Definitions

• • • • • • The following terms provide clarification: Codification is to arrange/sort policies and/or procedures into an organized system or code.

Policies mandate action or constraints. A policy is a concise formal statement of principles that indicate how an enterprise entity will act in a particular area of its operation. Procedures are the steps that make a policy happen, the method by which a policy can be accomplished. For the purpose of codification initiatives, procedures are outward facing instructions, those steps that are provided to our customers to help them accomplish a task mandated by a policy. Reconciliation is the process of review for ensuring procedures are consistent/compatible with institutional policies.

Standard Operating Procedures (SOPs) are inward facing instructions for staff, documentation of the standard for how internal tasks are done. SOPs describe workflow, and the inputs and outputs of a process. Well-written SOPs provide direction, improve communication, reduce training time, and improve work consistency across the Enterprise.

Project Scope

• • • Each Enterprise Unit will… Produce a list of services provided and major decisions supported by the actions of the unit.

Produce a set of SOPs that give step-by-step explanation of the process used by the unit to deliver the identified list of services or to support its decision making responsibilities.

Have codified standard operating procedures.

All SOPs will be collected into an internal library of services and procedures that will be reviewed and updated annually.

Stage I: Contact / Service Directory •Location of the Unit’s Base of Operation •Main Phone Number, Contact Number for services, Email Contact Information •List core functions of the Unit, including key services •For each service you provide for an internal customer, list SOPs for those services.

•For each core function performed internally – that is, an operational function -- list SOPs needed to carry out those functions.

•Identify any SOP you believe should remain confidential

• Using the template provided; all Units will develop SOPs for each service identified for the Unit • SOPs should provide sufficient information to insure that an Enterprise community member knows how to effectively interact with the process • SOPs should be sent to appropriate leadership for approval Stage II: SOP Codification • Using the template provided; all Units will develop SOPs for each service identified for the Unit • SOPs should provide sufficient information to insure that an Enterprise community member knows how to effectively interact with the process • SOPs should be sent to appropriate leadership for approval • All SOPs should be sent to the EVP with authority over the Unit for final approval • Once approved, SOPs should be added to the directory of services (PAWS)

Codification - Timeline

STAGE I: Identify needed SOPs/ List of Services STAGE II: Develop/Update SOPs Kick-off Feb-Jul 2014 Dec 2013 Jan-Feb 2014 Audit SOPs/ Electronic database Aug-Dec 2014 Progress reported monthly (20%)

Advisory/Steering Team

Risk Management Steering committee

Codification

Project Sponsor Dr. Azziz Functional Leader

Jim Rush

Project Resources

IT support services, Communications and Marketing

Enterprise Project Core Team Project Manager

Karen Ribble

University SOPs Team Shared Services SOPs Team

SOP=Standard Operating Procedure

GRHealth SOPs Team

Functional Teams - Codification

University SOPs Lee Little-Chair

• • • •

IRB (Tillman)

Library (Seago) Academic Programs: Summerville (Rychly/Wyatt)* Academic Programs: Health Science (IE-Whiting)* • • Research (Hamrick) MCG Regional Campuses (Martin) • Student Affairs (Frazier) • Admissions/Enrollment (Cibirka)* • Diversity (Guion) • Finance (Jones) • Legal * Additional areas • • • • • • • • • • •

Shared Services SOPs Jim Rush-Chair

Administrative (Wagner) Human Resources IT (Enicks) Purchasing (Trover) OCM (Brond) Facilities (Howard) Advancement (Barcus) IE (Brigdon/Ribble) Audit (Clay Sprouse) Government Affairs (Shaffer) Compliance • • • • • • • • • •

GRHealth SOPs Susan James-Chair

Medical Associates Ops (Terrilyn Jones) Medical Center Ops (Scott) MA/MC Ambulatory

(Thornton)

Professional Services (Gomez) Nursing (Perry) Periop (Ripollone) CMO-Med Staff/Quality Finance (Damron) Finance (Brownlow) Legal

The Role of Project Manager

Facilitates the project management processes by… • • • • • Developing documentation Ensuring sponsor agreement Identifying stakeholder communications Helping remove obstacles Monitoring and tracking issues

Status Reports

Communications Process

Stakeholder Analysis

Questions/ Issues

Project Management Team Core Team Monthly Meetings

Effective Meetings Request for support

Document Management via BOX

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Project Management

Accountability vs. Responsibility

Next Steps

1. Assign staff to represent area(s) on team (by 12/20) 2. Identify responsible persons within each units 3. Invitation to connect to BOX folder for SOP Project documents/templates 4. Establish team meeting dates for January 5. Work on list of services for unit

Questions?

UNIVERSITY Lee Little General Counsel

Legal Affairs 706-721-4018 [email protected]

SHARED SERVICES Jim Rush Chief Integrity Officer

Office of Compliance and Risk Management 706-721-1626 [email protected]

HEALTH SYSTEM Susan James General Counsel

Legal Affairs 706-721-5709 [email protected]