Healthcare Redesign Policy

HEALTHCARE REDESIGN POLICY

Policy Number:    Effective Date:    Next Review Date:

Purpose

This policy establishes requirements, responsibilities, and procedures for planning, approving, implementing and evaluating care delivery redesign initiatives that materially affect clinical processes, patient safety, or patient access. Redesign activities include workflow redesign, technology-enabled care model changes, staffing model adjustments, and physical space reconfiguration.

Scope

Applies To

Inpatient services
Outpatient services
Ambulatory/Clinic services
Administrative/support functions

Definitions

Redesign Initiative: a defined project to change clinical or operational processes that may affect patient care, safety, access, or privacy. Pilot: a controlled, time-limited implementation to evaluate effects prior to full deployment. Patient Representative: an individual designated to provide patient perspective during design and testing.

Policy Statement

All redesign initiatives that may materially affect clinical care, patient safety, patient access, or the use of protected health information must comply with this policy. No redesign that alters clinical responsibilities, care pathways, or patient-facing processes may proceed to pilot or implementation without documented approval by the Executive Sponsor and completion of the required risk assessment, privacy review, patient impact assessment, training plan, and monitoring plan.

Roles and Responsibilities

Redesign Process Requirements

Each initiative must include the following documented elements prior to pilot approval: assessment of current state; proposed changes and measurable objectives; patient safety risk assessment; privacy/data protection impact analysis; staffing and training plan; communications plan for patients and staff; pilot criteria and success metrics; and a rollback/mitigation plan.

Pilot and Evaluation

Pilots must be limited in scope and duration, with predefined stop/go criteria and validated measurement methods. Adverse events or unanticipated patient harm during pilot must trigger immediate suspension and review.

Training and Communication

All staff affected by a redesign must complete required training prior to deployment. Patient-facing communications must be prepared and approved by the Communications Lead and the Clinical Lead prior to release.

Patient Impact Assessment

Will redesign require patient consent or notification?: Yes No

Documentation, Record Retention and Compliance

All documentation related to redesign initiatives, including approvals, risk assessments, training records, pilot data and communications must be retained in accordance with organizational record retention policy and applicable law. Noncompliance with this policy may result in corrective action up to and including suspension of the initiative.

Review and Revision

This policy will be reviewed at least annually or sooner following significant regulatory change, adverse patient outcomes linked to redesign, or upon request by the Executive Sponsor. Revisions must be approved and documented in the change history.

Certification

By signing below the authorized signatory certifies that the information provided in this document is complete and accurate to the best of their knowledge, that required risk and privacy reviews have been completed, and that the initiative will be conducted in accordance with applicable laws, regulations, and organizational policies. The signatory further acknowledges responsibility for ensuring monitoring of outcomes and that corrective action will be taken if the redesign adversely affects patient safety or care quality.

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