Making a Cultural Shift

Change empowers staff to be part of the credentialing process

• By Greg Goyne
• Aug 06, 2014

Hospitals operate 24/7. As a result, countless numbers of people enter and exit their facilities. In order to provide a safe environment for their patients and employees, they need to know who these people are and why they are there.

LDS Hospital, a 217-bed community hospital in Salt Lake City, and part of Intermountain Healthcare, a not-for-profit health system with 22 hospitals, more than 1,000 physicians, and a broad range of clinics and services, decided to implement a supply credentialing program in 2000.

A credentialing program is one of the most effective ways for hospitals to improve patient safety, prevent infections and reduce adverse events. It enables them to obtain, verify and assess the qualifications of commercial visitors and ensure they have:

• Been screened by their employer;
• Gotten properly immunized;
• Received appropriate training;
• Passed a national criminal background check;
• Insured at a sufficient level; and
• Understand the hospital’s health and safety policies.

By requiring third-party visitors to have the proper credentials, hospitals can decrease the risks to staff and patients, and ultimately lower the costs of healthcare. To help achieve this goal, government agencies including the Centers for Disease Control and Prevention (CDC) and The Joint Commission are moving toward requiring greater accountability from all healthcare personnel, including every person who could come into contact with patients.

Focusing on the Credential

The LDS program was initially focused on credentialing clinical, pharmaceutical, medical device and service representatives to ensure they were registered, had the required immunizations and didn’t sidestep the purchasing department to meet directly with physicians. However, the program’s focus rapidly evolved from credentialing to making the hospital a safer place for employees, patients and suppliers.

The hospital originally tried to implement the program manually by having suppliers submit forms and attend orientation classes. Immunization records were stored in plastic tubs in the surgical services department. Suppliers were supposed to go to the Purchasing Department and signin when they had an appointment, but the process had variable consistency, at best.

That was when Intermountain Healthcare decided to evaluate electronic vendor credentialing systems to meet The Joint Commission requirements for all Intermountain facilities and help standardize processes inside this hospital and across Intermountain’s network of hospitals.

Doing the Homework

According to JoAnn Autenrieb, supplier access program manager for Intermountain Healthcare, they did their homework before implementing their vendor credentialing system, and this made all the difference. In 2006, Intermountain’s supply chain department created a committee that included Autenrieb, surgical services, material management, compliance, operations managers and purchasing to evaluate and select a system. The committee chose the Reptrax vendor credentialing system provided by IntelliCentrics.

Reptrax is a healthcare industry vendor privileging system and has an installation base of 6,000 facilities and nearly 500,000 users. Suppliers can check in and out of a healthcare facility and receive a printed badge, if they comply with the hospital’s policies and credential requirements. If they aren’t compliant, access will be denied and they will not receive a badge. These badges are time-sensitive, feature photo identification, display the patient being visited and clearly show which area of the facility they are allowed to enter.

“Access tracking and ensuring that people entering patient care areas have the appropriate credentials are key focus areas for the program,” said Heath U. Jones, director of program development at Intermountain. “However, ensuring compliance is not a small feat since it is estimated that hospitals typically have as much foot traffic in their lobbies as a large shopping mall.”

Implementation

To streamline implementation, the committee spent the following year meeting and arming hospital managers and supervisors with talking points for how to work with suppliers and how to handle difficult situations.

Intermountain also took this time to establish policies and procedures. According to Autenrieb, reps are not permitted access simply because they passed a background check and had the correct immunizations. They also must illustrate a need for access, be a properly-contracted supplier, read and understand Intermountain’s policies, view an orientation video, and sign and date a form indicating their agreement. Suppliers are also required to comply with hospital policies when checking in to receive a badge. In addition, Intermountain’s 34,000 employees feel empowered to ask suppliers, “Where’s your badge?” if they see a representative without one.

“We’ve built a culture of accountability and responsibility,” said Joe Walsh, assistant vice president of procurement at Intermountain. “Everyone is responsible for quality management and creating a safe work environment.”

Walsh said that the key to creating this type of cultural change was executive involvement. The CEO at each hospital supported this initiative, as did Intermountain’s executive leadership. In fact, Intermountain’s chief medical officer was instrumental in having physicians ultimately embrace the program. Cross-functional teams were also developed to pull all stakeholders together and create consensus-driven decisions.

Standardizing Practices

Since LDS Hospital and Intermountain first started using Reptrax, it has become part of day-to-day operations within this healthcare system. Not only has the program helped standardize practices across the organization, but it has also helped uncover a number of things that could have impacted the health, well-being and safety of their employees and patients. For instance, when Intermountain first started conducting background checks, they learned that some reps had criminal records, including sexual offenses. In addition, they found a couple of people with live tuberculosis, one of whom was a medical device representative.

Standardizing the requirements for suppliers to access different departments was part of this cultural change that also included Intermountain’s move to a system-wide central purchasing system. This has made compliance easier for suppliers, while helping Intermountain ensure all of its hospitals are paying the same price for an item. In addition, having the right processes in place when the program launched has meant Intermountain hasn’t had to make major changes to the program since it was put into place.

“Today, supplier management continues to be a major initiative within Intermountain,” Jones said. “The program has evolved to better support our suppliers, who serve a critical role in our mission of delivering extraordinary patient care.”

Intermountain’s staff has truly embraced this program that focuses on identification, education, awareness and accountability. Currently, suppliers are required to make appointments via the software, which has helped eliminate the number of suppliers making cold calls. Also, employees now use Reptrax to help reach out to suppliers or run a report to determine which suppliers they met with over a specific period of time. With the assistance of educational tools, such as video scenarios, this supplier management program promotes a culture of accountability, where everyone is responsible for quality management and creating a safe work environment. However, suppliers are just one type of visitor in need of credentialing. To ensure all types of visitors including volunteers, students and contingent laborers, continue to receive proper credentialing, Intermountain has created a program called Intermountain Facility Access. This program uses best practices to identify the visitor by type to determine the risk level, security level, product/service competency and credentialing requirement needed for the badge.

This article originally appeared in the August 2014 issue of Security Today.