Ellis Hospital: Taking Steps to Make Our Hospital a Safer Place
In order for hospitals to maintain a safe and secure environment for their patients and employees, they need to know who is visiting their facilities and why they are there. The challenge is how to track these visitors, determine if they are who say they are and find out if they have the proper immunizations, background checks and training. In addition, the Joint Commission and other government agencies include "unpaid" individuals in their definition of healthcare personnel. This means vendors and suppliers need the same background checks and immunizations as hospital employees.
At Ellis Hospital — part of Ellis Medicine, a 438-bed community healthcare system in Schenectady, N.Y. — we are taking a closer look at the professionals who visit our facilities as part of our ongoing security efforts. Not only are we trying to limit the vendor’s unannounced visits to physician offices, we have also employed formal credentialing programs for vendors and suppliers. However, successfully implementing this type of program doesn't happen overnight. It requires cultural change, and hospital employees need to embrace the program in order for it to be successful.
Hospital administrators at Ellis Medicine decided implementing a vendor credentialing program would help it achieve the Joint Commission's recommendations and improve hospital safety. We originally tried to manage our own vendor credentialing program. We had a file cabinet filled with folders and distributed registration packets, asking vendor representatives to submit their credentials and immunization records. However, the paperwork was often not returned. In addition, vendor representatives and suppliers were supposed to register at the purchasing department when they entered the hospital. However, vendors thought it was inconvenient to go to purchasing to sign in and often found ways to enter the hospital without doing so.
Despite our best efforts, we realized we didn't have the administrative staff to effectively manage the paperwork needed to track the thousands of vendors who came into the hospital, let alone ensure they were registered and had the required immunizations. As a result, the hospital turned to IntelliCentrics' Reptrax™ program to manage our vendor credentialing, monitor who is in the facility and track vendor behavior and their adherence to hospital policies.
Ellis Medicine's purchasing department first heard about Reptrax at a Yankee Alliance group purchasing organization meeting and got the approval of the hospital administrators to move forward with implementing the program. But before we implemented the hospital-wide program, the purchasing department wanted to complete its due diligence. It worked with the hospital's administration, infection control and employee health departments to get a better understanding of the credentials and immunizations required for hospital employees and applied these same requirements to vendor representatives and suppliers.
We installed the Reptrax system in 2009 and required that all pharmaceutical reps, medical device reps and vendors be credentialed. We installed kiosks at key locations, such as entryways and registration areas throughout the hospital, as well as on the other Ellis Medicine campuses including Bellevue Women's Center and Ellis Health Center. We also installed the system in the health system's purchasing department. Additional kiosks were also placed outside the areas of greatest concern — the operating rooms.
After installing the system, we thought the number of vendors complying with our hospital policies would immediately improve, but this wasn't the case. The reason: Hospital employees were not reporting the vendor representatives who weren't wearing a Reptrax badge. They assumed this was something the security department handled and never questioned it further.
After seeing our compliance scores, it was clear purchasing could not be the only department responsible for monitoring vendor badges. All hospital employees needed to embrace the program and feel empowered to make a difference. Purchasing created a team to educate employees about vendor credentialing and the important role they played by serving as the hospital's eyes and ears.
The department also realized new employees were joining the hospital's workforce all the time, so we made sure information about the vendor credentialing program was included in the new employee orientation packets. Today, employees are required to inform the purchasing department if they see a vendor without a badge. By the same token, if a vendor representative comes into a department unannounced, hospital policy requires staff to send the vendor representative to purchasing before meeting with them.
Initially, the hospital didn't understand the strength of the relationship between physicians and surgical representatives, particularly those in the orthopedic area. Orthopedic representatives work closely with surgeons, and the physicians were worried their orthopedic reps could have their privileges revoked due to credentialing issues.
Together with hospital administration, representatives from the hospital's purchasing department met with the surgeons to explain that the program was not designed simply to save money or to create roadblocks for vendors. Instead, it was designed to improve the safety and security of the hospital's patients, employees and visitors.
We also explained that the program ensures all vendors and suppliers meet the same safety requirements as hospital employees. Once we reached an understanding, getting the cooperation of both surgeons and surgical representatives became a smooth process.
To improve compliance, the purchasing department monitors the system throughout the day. If we see that a representative has checked into the hospital and doesn't have the correct credentials, we contact the department and ask them to send the representative to purchasing. We also send an email to the representative directly instructing them to contact purchasing.
We also run compliance reports multiple times a week to ensure that vendor representatives have the correct credentials for access to the areas they are visiting and, when appropriate, we restrict their access. For example, there are times when a vendor representative might register to go to the administrative offices — which have fewer compliance requirements — but actually visit a clinical area with more stringent requirements. Checking vendor credentials and determining where they go in the hospital helps identify these policy breaches.
By the same token, the hospital understands vendors need to visit the hospital and meet with physicians in order to do their job. As a result, purchasing runs a daily report to restore access to those representatives who have addressed their compliance issues.
Vendor credentialing not only helps Ellis Hospital know who is visiting the facility but also helps make sure vendors and suppliers have the appropriate immunizations.
Hospitals across the country are enforcing new policies that require all hospital employees to receive flu shots. Our vendor credentialing program makes it easier to ensure all vendors and suppliers who enter the hospital are appropriately vaccinated. Beginning in 2013, CMS began requiring hospitals to report employees' flu vaccination rates. Eventually, the data will be posted on the agency's Hospital Compare website.
The program continues to grow. Over the last several years, Ellis Medicine has acquired a number of clinical and physician offices and currently has nine different facilities utilizing Reptrax access management. Rather than installing additional kiosks in these offices, we installed the program on administrative computers. These locations require the vendors to schedule a meeting request through the program. The administrative assistant receives the email request, which they approve or deny after reviewing the required credentials. If approved, the rep will simply stop at the admin's desk and check in. Printed badges aren't required since these offices are smaller with only one entry point.
Coleen Norberg has supported Ellis Medicine’s supply chain efforts for 39 years.