Amanda Gentry leads the newly created UMMC Office of Policy, the ‘ultimate resource’ for all policies, procedures and guidelines at the Medical Center.
Amanda Gentry leads the newly created UMMC Office of Policy, the ‘ultimate resource’ for all policies, procedures and guidelines at the Medical Center.
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New office ultimate resource for UMMC policy management

Published on Monday, November 30, 2020

By: Bruce Coleman

A seasoned professional familiar with all aspects of administrative policies, procedures and guidelines is leading a new executive office that serves as the final authority on internal policy creation and management at the University of Mississippi Medical Center.

Amanda Gentry, who gained knowledge and insight into the drafting, approval and administration of governing documents as a registered nurse, performance improvement coordinator, Epic application coordinator/analyst and information technology project manager at UMMC and, most recently, as a population health associate at Vanderbilt University’s Medical Center, returned to UMMC in March to lead the institution’s new Office of Policy.

Serving as the ultimate resource for all of the Medical Center’s policy management would be a daunting challenge for anyone, but Gentry, who received her nursing degree from UMMC, said the opportunity to streamline what had become a complicated and unwieldy process at the institution was impossible to resist.

“In the past, UMMC has not had anyone specific to help with the many types of policy and procedure documents,” she said. “As a result, sometimes documents are created that are in conflict with one another, which is a risk to the organization.

“What I’m trying to do is provide one centralized location for corralling all of our documents, such as policies, procedures and guidelines - all of those things that live in the Document Center today. My office is designed to be the gatekeeper, to standardize our document formats and ensure each document will serve its intended purpose.”

For example, she said, “Sometimes people create a document and call it a policy when it’s actually a procedure. I’m here to guide the document owners as they define what they need the document to do for them and to ensure the document owners understand UMMC’s document type definitions and that they are selecting the right document for their needs.”

A longstanding institutional goal of Dr. LouAnn Woodward, UMMC vice chancellor for health affairs and dean of the School of Medicine, has been to standardize policy management across all six of the Medical Center’s schools and throughout all three of the institution’s mission areas.

Michael Henderson Headshot

According to Dr. Michael Henderson, UMMC chief medical officer, the focus will begin on UMMC’s health system, where improving policy management “has significant clinical and regulatory implications.”

“How academic medical centers function is, at least in theory, largely defined by following its policies,” said Henderson, who implemented an effective policy creation and management system himself while serving as chief quality officer at the Cleveland Clinic from 2010-15. “Policies should be simple, brief and concise to define the big picture requirements and be supported by standard operating procedures, guidelines, directives, protocols, etc., which do not carry the authority of the policy.

“Different schools, departments and smaller groups have done policies their own way without standardization. This has led to shortcomings, such as duplications, conflicting policies and many documents filed as policies that belong in other categories. Having a system in place to assure standards are set in writing, reviewing, approving and updating documents is the rationale for this office and will be of enormous benefit to UMMC.”

One of Gentry’s initial tasks has been to obtain a software solution that would best meet the varied document needs of the Medical Center. The institution has been relying on a homegrown program that can be difficult to search and navigate: Gentry is guiding the acquisition of a policy and procedure management tool customizable to handle all of the Medical Center’s documents.

“This solution will allow us to better manage our documents, find them easier and categorize them by site,” she said, “so you’re not in a Jackson hospital reviewing a document that’s intended for use in our Grenada hospital.

“It’s a big undertaking to try to implement new software and manage UMMC’s over 4,000 documents.”

Which is where her professional experiences at UMMC and Vanderbilt come into play, shaping her foundational approach to policy creation and management.

“As a nurse, much of what you do is guided by regulatory standards,” she said. “Performance Improvement plays such a huge role in making sure we provide quality care for our patients. PI is about data and standardized processes - how we can make things better and create a system that ensures quality outcomes. This experience allows me to see the key roles these documents play, especially in the health care setting.

“My time spent in DIS (UMMC’s Division of Information Systems) as both an Epic applications analyst and as an IT project manager has given me insight into how a product like PolicyTech is managed. I understand application parts and pieces and how they are integrated to create a robust system as a whole.

“As an employee of Vanderbilt University Medical Center, I worked here in Mississippi with different practices in our communities as those practices focused on population health and process improvement. This experience allowed me to go into all types of practice environments and work with each one to meet its goals.

“It’s all about meeting people where they are. When you’re thinking of process improvement, you have to break it down into digestible pieces and think about both intended and unintended consequences. This is how I approach our policies and procedures - where are we now, where do we need to go and how can each document help us get there.”

Returning to UMMC at the onset of the COVID-19 pandemic would have been even more challenging had she not already secured relationships with many of the institution’s policy leaders.

“I’m excited for the opportunity to return to the Medical Center and work with many people I know from my previous roles,” she said. “UMMC has always felt like home and it felt right to return, even in the middle of a pandemic. I get the unique opportunity to provide a service to everyone here.

“I find so much joy in being able to assist people with their documents. Many people have inherited a document and they aren’t always sure about what to do with it. I’m able to step in and help them create what they actually need.”

Her attention to detail, her insistence that all of the Medical Center’s documents be individually “touched” and that they go through the correct review and approval process, are why Henderson predicts Gentry will bring great value to the institution.

“The most important ingredient to success for this effort is having the right leader,” he said. “Amanda brings knowledge and passion to her role as director of the new Policy Office. She understands the need for a robust document management system, getting buy-in from users and standardizing processes.”

Gentry said she hasn’t had any trouble obtaining that buy-in, especially when policymakers at UMMC learn of the services her office can provide them.

“Everybody I have dealt with has been so excited to have a centralized location for assistance,” she said. “People want to do the right thing regarding policies and procedures, they just don’t always know what that is. Now they can reach out to me and I can walk them through the process.”

For more information or to make inquiries of the Medical Center’s new Office of Policy, email