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Slides and Handouts Organizing Clinical Information Systems to Manage and Improve Care Jennifer Allan, BSN, RN Methodist Healthcare System Jane Englebright, PhD, RN Columbia/HCA Healthcare Corporation Our Documentation System 1994 to 1996 • Four sites using a computerized clinical documentation system – Two using NANDA format – Two using NIC format • One site on paper Unresolved Problems Included: • Increased charting time, increased cost • Ambiguous, complex care plans • Hundreds of documentation screens • Physician dissatisfaction with nursing • Physician dissatisfaction with medical record • Fragmented, duplicative and conflicting information in the medical record “Fix” the System or De-install! • Meet legal, regulatory & clinical requirements • Decrease documentation time • Reduce costs • Eliminate repetition • Streamline record • Automate reports • Introduce interdisciplinary documentation • Lay foundation for quality monitoring • IMPROVE PATIENT CARE Two Early Rewrites Used Established Nursing Taxonomies Advantages Disadvantages NANDA Well known to Foreign to non- nurses nurses Non-exclusive diagnoses NIC Facilitates Long look-up for charging and interventions acuity Does not tie to care plan Review of Literature • NIC (Nursing Intervention Classification) • NANDA (North American Nursing Diagnosis Association) • Charting by Exception • Focus Charting • Problem Oriented (SOAP) • Practice Guidelines No current methodologies supported our vision: Concepts from NANDA, Our NIC, Charting by Goals Exception, Systems Theory Patient Centered Documentation © Methodist Healthcare System of San Antonio, Ltd.. Patient Centered Documentation • Single standard of care • Standards of practice for each patient care area • Rapid charting • Detailed patient assessment information • Automated connections between phases of care process • Clinical guidelines Any patient entering the MHS system at any level : Receives the same Standard of Care Consistent Standards of Practice at all facilities across all “like” patient care areas Patient Centered Documentation The foundation of the system is the Standards of Care for the Methodist Healthcare System Patient Centered Documentation Each patient care area within all facilities has identified standards of practice for defined patient populations • Common interventions – Shift Assessment –Vital Signs – Discharge planning Patient Centered Documentation Intervention Data Yes Custom screens Required developed No No Separate Minimum intervention or Expectation delete Yes Bundled Intervention Bundled Intervention = Care Area Statement • Unless otherwise documented the following assessments and interventions have been verified: • If on bedrest, patient turned q2h • Assisted with personal hygiene q24h • Linen changed as needed to maintain hygiene and comfort • Privacy provided Patient Centered Documentation Developmental Age Guidelines will be a component of each patient’s care. •Infant • Young Adult • Toddler •Middle Age • Preschool • Older Adult • School Age • Developmentally • Adolescent Delayed Patient Centered Documentation Admission Admission Care Plan Triggers Assessments Nursing Standard of Care Patient Type PT Standard of Patient Age Group RT Practice Pharmacy Age Guidelines Dietician Problems Individualized Plan of Care Standard of Care Standards of Practice Age Guidelines Interdisciplinary Plan of Care Problems from Interdisciplinary Physician Orders Assessments Plan of Care Patient Problems Unit Care Guidelines Standards of Practice Age Guidelines Hospital Standard of Care Patient Centered Documentation Problem List • Interdisciplinary • Systems framework • Actual problems for this episode of care • Potential problems requiring intervention Problems, Guidelines and Interventions Problem/ Guideline Intervention Order Neurological None Neuro Assess High Risk Fall Fall Fall Precautions Precautions Chemotherapy Chemo None Patient Centered Documentation Documenting Care • Documentation screen mirrors care plan • Detailed documentation of abnormal assessment findings • Abbreviated documentation of routine care Patient Centered Documentation Back to Basics • Quality measurement tool • Regular measurement of performance of care standards • Patient interviews and observations Pilot Study 1997 • 4 med/surg units •Time spent • 3 months documenting • Incremental overtime • User satisfaction Documentation Time 40 35 30 25 Nurses per shift 20 Mean charting minutes 15 per patient 10 5 0 Apr-97 May-97 Jun-97 Jul-97 * No change in ADC or Acuity Incremental Overtime 16 14 12 10 Mean Hours of 8 Incremental Overtime 6 Per Shift 4 2 0 Apr-97 May-97 Jun-97 Jul-97 An 8.2% Decrease in Salary Per Patient Day Nurse Satisfaction N = 30 18 16 14 12 10 Apr-97 8 Jul-97 6 4 2 0 1 23 Satisfied4 5 Very Dissatisfied Satisfied Nursing Administration Took Ownership!! • Strategic objective for all five hospitals in system • System design process and organizational structure defined • Specific goals and expectations established for system • Resources allocated across system Synchronization required to meet goals • Charting philosophy • How documentation is • How documentation is accessed electronically done and on paper Challenges • Large investment in current systems • History of not working together • Different levels of experience with computer systems • Multiple specialty programs • Resistance to change Goals • Clear and concise medical record • Meet or exceed regulatory requirements • Improve staff efficiency • Improve patient care processes and outcomes • Enable clinical research Organizational Structure Clinical Informatics Coordinator Roles Hospital A Hospital B Hospital C Hospital D Med/Surg/ Jennifer ICU Rehab/SN Linda U/Psych Ancillary Cindy Maternal/ Jean Child Clinical Information System Accountability Structure Nurse Executive(s) Steering Committee PCM Coordinators Clinical Medical Advisory Legal and User Groups Education Managers Committee(s) Risk SMEs Organizational Structure Steering Committee • Oversee documentation and policy development • Insure appropriate experts have input • Mediate conflicts • Maintain focus on strategic objectives Ground Rules • 80/20 Rule • Interdisciplinary commitment to no duplicate documentation • All data collected must be used for some purpose • One discipline cannot “dump” data collection responsibility on another Developing Clinical Documentation Largest User Group Multidisciplinary Regulatory & Legal Clinical Input Review Approval Implementation Iterative Process Next User Group Multidisciplinary Regulatory & Legal Clinical Input Review Approval Implementation Implementation • March 1998 installed in 4 sites already using electronic documentation • September 1998 installed in 750 bed facility with no electronic documentation 25000 1.20 1.00 20000 0.80 15000 0.60 10000 0.40 5000 0.20 0 0.00 Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- 98 98 98 98 98 98 98 98 98 98 98 98 99 99 99 99 99 99 OT Hours OT Hours per Adj Pt Day Working Together Pays Off • Design: • Maintenance: 5 FTEs for 6 5 FTEs for 5 months hospitals Evaluating Care Initial Assessments Care Plan High Risk Screens QI Reports Screening Tools Consult Reports Worksheets Chart Audits: Admission Assessments MICU 100 95 90 % Completed 85 80 Mar Apr May Jun Jul Evaluating Care Daily Documentation Medical Record Notes Graphs Profiles Variances Audits QI Reports Revenue Support Chart Audits: Daily Documentation Daily Documentation MICU 100 90 Care Area 80 Statement 70 Care Plan Evaluations % Completed 60 50 Mar Apr May Jun Jul Example: Restraints Daily Documentation of Immobilization & Restraints Report on Each Item of Immobilization & Restraint Protocol Report to Managers for Trending and Follow-Up MSTH Nursing “LIVE” RESTRAINT Dates: 01/01/99 to 12/14/99 Acct # N350409782 77 M Date Time Dang Self Grossly Explain Mental Restraint Circ Skin Order / Others Innap. Beh To Pt Status Type/ Loc Check Cond. Ver. _______________________________________________________________________________________ 10/09 1600 Y Y Y Combat Posey Vest/ Y N Y Bilat Ankles 10/09 1915 Y Y Y Combat Posey Vest / Y N Y Bilat Ankles 10/09 2000 Y Y Y Combat Posey Vest/ Y N Y Bilat Ankles 10/09 2100 Y Y Y Combat Posey Vest/ Y N Y Bilat Ankles Example: High Risk Falls Q 8 Hour Documentation of Immobilization & Restraints Daily or Shift Report of Fall Risk Score, Bedcheck, Education Report to Managers for Trending and Follow-Up Figure 11 Methodist Hosp/Children's Hosp FALL RISK REPORT LOCATION: H.ORTH PATIENT: UNIT #: AGE/SEX: 86 F ROOM/BED: H.334 A ACCT #: DATE TIME SCORE BC # SIDERAILS INSTRUCTION 12/13/991237 8 Y 4 Y 12/13/991700 8 Y 4 Y 12/14/990250 8 Y 4 Y PATIENT: UNIT #: AGE/SEX: 60 F ROOM/BED: H.314 A ACCT #: DATE TIME SCORE BC # SIDERAILS INSTRUCTION 12/13/991942 5 N 4 Y 12/14/990231 5 N 4 Y 12/14/990745 5 N 4 Y TOTAL # OF DOCUMENTATIONS: 124 Example: Nutrition Nutrition Eval Dietician Nutrition Intervention Completes Nutritional Risk Problem? Added to Eval Assessed on Care Plan Admission Problem, Goal, and Interventions Nutritional Risk to Care Plan Report to Dietician Daily Monthly QA Report METROPOLITAN METHODIST HOSPITAL 1999-2000 % Patients @ Potential for Nutritional Risk by Priority Based on Total Admissions 100% 40% 34% 38% 37% 42% 80% 46% 60% 52% 57% 40% 55% 55% 50% 48% 20% 8% 8% 6% 8% 8% 0% 0% 0% 0% 0% 0% 0% 8% Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Potential High Risk Potential Moderate Risk Potential for Status Change Regulatory Requirements • Three JCAHO surveys with results of each benefiting all five
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