SPECIAL REPOR T:

Nursing, Technology, and Information Systems

This special report is sponsored by Cerner Corporation and the Healthcare Information and Management Systems Society (HIMSS). All articles contained in this special report have undergone peer review according to American Nurse Today standards. s m e t Enabling the ordinary: More time to care s y

S Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, and Susan Hamer, DEd, MA, BA, RGN n o i t a Versions of this article appear in is what nurses do, m American Nurse Today and what nurses do is coordi -

r (United The value of o States) and Nursing Times (Unit - nate and deliver care. So al - f n ed Kingdom) to acquaint readers though the context, technology,

I technology in with common goals, challenges, and needs of our popula - d tions have changed, nurses re - n and advances in using health in - automating and a

main the foremost providers and

, formation technology to enable y nurses to provide safer and more coordinators of care. g improving Why state something so obvi - o efficient care. l ous? Showcasing the caring o

n care aspects of nursing in a techno - h logically dominated world is c e — challenging. Technology enables T

, round the globe, in care and enhances safety by au - g every setting, nurses seek ening issues come to the fore - tomating functions both simple n i Ato provide care to pa - front. On the other hand, in the and complex. It doesn’t replace s

r tients and families to keep them (UK), the de - nurses. As one expert cautions, u safe, help them heal, and return bate over resources that has automation should occur in N

: them to the highest possible lev - been playing out in the media nursing, not of nursing. The val - T

R el of functioning. Nowhere is the has caused confusion and public ue of technology hinges on how

O struggle to achieve these simple uncertainty as to whom to be - it’s used and whether it helps or P

E aims more apparent than in lieve, undermining confidence in hinders care. R . The tightrope of bal - the system as a whole. The nurs - L

A ancing what nurses believe to be ing hasn’t been

I Changing nursing practice

C adequate resources for high- spared this negative view and safely E

P quality care and the affordabili - has needed to reassure the pub - So why do nurses have to strug -

S ty of these required resources are lic of its core values and pur - gle so hard to get the technology often at odds. Disagreement pose—that caring and compas - we need to support our practice? among leaders in healthcare de - sion are part of the core business And when this technology is livery systems as to how to allo - of nursing. available, why don’t we reap the cate nursing resources has led to tension and discord. Despite decades of showing that the amount of care provided by registered nurses directly affects mortality and morbidity, nurse leaders continue to have to justi - fy requests for nursing resources. Universally, the desire to make care more affordable has fueled efforts to make care more efficient and effective. The public recognizes this means examin - ing all aspects of care in the pur - suit of cost-reduction measures that will not reduce quality. In the United States, nurses contin - uously rank as the nation’s most trusted professionals by the Gallup Poll and have the pub - lic’s support whenever belt-tight -

American Nurse Today Volume 8, Number 11 www.AmericanNurseToday.com SR2 S benefits we’ve been seeking for P E our practice? C

Comparing the U.S. and UK health systems I For years, many in the health - A care community believed nurses Despite some fundamental differences, healthcare delivery systems in the United L R

were too slow to embrace new States and the United Kingdom (UK) share a national commitment to quality and E the role of nurses in improving care. In both nations, nurses are expanding the use P technologies and might disrupt O or even obstruct the change of health information technology tools to improve safety and efficiency and R involve in their care. The chart below compares some features of the U.S. T :

process. Had they ever visited a and UK health systems. N

neonatal or intensive care unit? u

Although their description of Feature United States United Kingdom r s nurses and nursing wasn’t accu - i n

rate, it had become a mantra Payer(s) • Government • Government g , within a wide variety of organi - • Private companies (National Health Service [NHS]) T zations. • Self-pay • Private insurance companies e • Private payers c

What they failed to grasp, h and continue to misunderstand, n

Delivery • centric (government • Strong community-based care o are the practical realities of how l

system or private) with primary-care focus o change and how to • Increasing shift toward • Hospitals run by trusts g support in practice. illness prevention and more (public-sector corporations y ,

For generations, nurses have ambulatory, home, and providing services for the NHS) a changed their practice success - post- n d

fully and have adapted to new I challenges, such as coping with Technology • • Paperless system by 2018 n f rising patient acuity, safely de - vision for all citizens by 2014 • Improved availability, o • Improved availability, quality, quality, and safety of r livering dangerous drugs, and m and safety of information information preventing adverse events. And a t

they did this in a world where i o

management theories were only n

beginning to address nursing Many of these organizations S and healthcare settings. The United States and UK treated technology to help nurs - y s

At times, the need for change es deliver care as a separate t

share similar goals for e

has been critical and the re - case, viewing it as an additional m

sponse of the nursing profession technology innovation but cost to services rather than a s has been swift. Of course, we mechanism to enhance care. can all acknowledge there are differ in the economics Thus, the possibility of being un - aspects of care we should have able to sustain the technology changed but have resisted. Nurs - and delivery-system was always real. ing professionals have sought to configurations. Increasingly, health technolo - understand how to change our gy projects have been seen as practice and increase the avail - special projects that need special able evidence on which to base if the addition would increase teams set up by senior man - our care. We understand how to the workload or change work agers, some of whom are unfa - change practice safely and how practices or whether it would be miliar with the care setting. to sustain those changes. acceptable to patients. Organi - These managers seem to struggle zations supported technology with focusing on supporting Shared vision for implementation to achieve busi - frontline practitioners to deliver technology: Enhancing care ness goals, whereas nurses saw care. Managers have failed re - The United States and UK share practice development as the peatedly to enable ordinary day- similar goals for technology in - real goal. to-day care with technologies. novation but differ in the eco - The focus on the business case The need for technology to nomics and delivery-system con - addressed primarily organiza - support practice was demonstrat - figurations. (See Comparing the tional benefits, such as the de - ed by findings from the Technol - U.S. and UK health systems .) With sire for technology to replace ogy Drill Down project of the the technology explosion, many staff time and the ability to American Academy of Nursing’s healthcare organizations have market to patients the use of Workforce Commission. Frontline sought to add new systems “cutting-edge” devices and elec - nurses and other multidiscipli - rather than integrate existing tronic record systems, not pa - nary care team members stressed ones—usually without knowing tient experience and outcomes. the importance of involving di -

www.AmericanNurseToday.com November 2013 American Nurse Today SR3 s rect caregivers in technology de - m sign, selection, and testing—steps e Making care safer and more efficient with technology t often overlooked in the haste of s

y acquiring systems or devices. (See The American Academy of Nursing’s Workforce Commission recognized the S Making care safer and more effi - importance of effective technologies in improving the safety and efficiency of n cient with technology .) care and in helping to return time to nurses for essential care. The Commission’s o i Technologies designed for and Technology Drill Down (TD2) project, funded by the Robert Wood Johnson t Foundation, addressed another looming in an attempt to a used by nurses at the point of reduce demand for nursing care. Aimed at finding technological solutions to m care haven’t always been easy to r workflow inefficiencies on medical- units, TD2 brings together o use. A recent international sur - f multidisciplinary teams to review the current state of nursing workflow, design n vey seeking to identify priorities the desired future state, and brainstorm technology solutions to fill gaps—with I for nursing informatics research the over arching goal of providing safer, more efficient care. d on patient care acknowledges n The Commission found that in the 25 acute-care hospitals involved in the a

that despite the growing evi - TD2 project, most units already had supply storage systems, electronic nurse , y dence base on the design and documentation, provider order entry, and several other automated systems in g evaluation of health informa - place, such as telecommunications equipment and drug-dispensing units. o l tion technology (HIT), these Nurses wanted technology solutions to eliminate or automate work, perform o required regulatory functions, and provide ready access to resources. They were n technologies focus mainly on h medical practice. The study disappointed that much of the existing technology wasn’t user-friendly and c required work-arounds. Nurses also stressed the importance of vendors listening

e found that the two most highly

T to the voice of the staff nurse to make technology more functional and

, ranked areas of importance were meaningful. They recognized the value of technology in eliminating waste in the g the development of systems to nursing workflow due to inefficient work patterns, interruptions, or distractions; n i provide real-time feedback to missing supplies; and inaccessible documentation. These findings support the s r nurses and assessment of HIT’s business case for using technology to return more time to direct nursing care u effects on nursing care and pa - and to improve communication and implement other safeguards available N

: tient outcomes. through smart devices. T R O

P Agenda for leadership

E We know how to support high- R quality professional practice de - byproduct of excellent clinical International priorities for research in nurs - L

A velopment and what conditions practice and drive standards ing informatics for patient care. Stud Health I Technol Inform . 2013;192:372-6. C enable professions to change for high-quality data from nurs - E Evenstad L. Cameron announces £100m P rapidly. If a profession is encour - es. The profession has made nurse tech fund. E-Health Insider. October 8, S aged to annex new forms of progress in dispelling the myth 2012. www.ehi.co.uk/news/ehi/8109/ knowledge and opportunities, it that nurses are slow technology cameron-announces-%C2%A3100m-nurse- can rapidly develop appropriate adopters. With the help of nurs - tech-fund. Accessed September 22, 2013. practice to self-adapt. This is the ing informatics experts, nursing Hamer S, Collinson G. Achieving Evidence- route to successful, sustainable leaders must continue to debate Based Practice: A Handbook for Practition - innovation. Nurses must address the issues that will help us lever - ers . 2nd ed. Baillière Tindall; 2005. the leadership challenge of how age technologies to improve care Newport F. Congress retains low honesty rat - to respond to and accelerate and efficiency and achieve the ing. Nurses have highest honesty rating; car salespeople, lowest. December 3, 2012. adoption of technologies to sup - promise that health technology www.gallup.com/poll/159035/congress-re - port practice. We need nurse can transform care. n tains-low-honesty-rating.aspx. Accessed Sep - leaders who see technologies as tember 22, 2013. promising solutions, not prob - Selected references Plochg T, Hamer S. Innovation more than an lems, and are able to integrate Aiken LH, et al. Effects of nurse staffing and artefact? Conceptualizing the effects of draw - nurse on patient in hospi - technology into their vision for ing into management. Int J Health - tals with different nurse work environments. care Manag . 2012;5(4):189-92. meeting practice needs. Nurse Med Care . 2011;49(12):1047-53. Simpson RL. The softer side of technology: leaders need to model and pro - Bolton LB, Gassert CA, Cipriano PF. Technol - How it helps nursing care. Nurs Adm Q . mote examples of enabling tech - ogy solutions can make nursing care safer 2004;28(4):302-5. nologies and demand systems and more efficient. J Healthc Inf Manag . that meet practitioners’ needs. 2008;22(4):24-30. Pamela F. Cipriano is a senior director for Galloway As technology matures, nurses Cummings J, Bennett V. Compassion in prac - Consulting in Marietta, Georgia, a research associate professor at the University of Virginia School of and other healthcare profession - tice: Nursing, and care staff: Our vision and strategy. December 2012. Nursing, and editor-in-chief of American Nurse Today . als should be able to collect in - www.england.nhs.uk/wp-content/uploads/ Susan Hamer is the organizational and workforce formation only once and see it 2012/12/compassion-in-practice.pdf. Ac - development director at the National Institute for reused often. Management infor - cessed September 27, 2013. Health Research Clinical Research Network at the mation should serve as a Dowding DW, Currie LM, Borycki E, et al. University of Leeds, England.

American Nurse Today Volume 8, Number 11 www.AmericanNurseToday.com SR4 S P E C I Collaborating on technology: A learning A L R E P O

exchange between U.S. and U.K. nurses R T :

Christel Anderson, MA, and Cathy Patterson, MSN, RN, MHA N u r s

colleagues at three Chicago i n

An immersion study healthcare facilities, all of which g ,

echnology implementation have achieved Magnet Recogni - T

in the clinical setting isn’t tion ® from the American Nurses e

found that shared c

Ta project but rather a Credentialing Center. Many h transformation of the delivery Magnet ® attributes became ap - n

governance helps o system. As healthcare services parent to the delegates during l in the United States and United these visits. (See o healthcare Understanding g ® Kingdom (UK) embrace technol - the Magnet Recognition Program . ) y ,

ogy to drive reforms in quality Each of the three facilities had a and efficiency, growing oppor tu - organizations keep up a specific focus: n d

nities exist to share experiences • Advocate Illinois Masonic I between the two countries. To - with technology. Medical Center: Connecting n f day, many global nursing dia - the community through in - o r logues are sharing lessons about — formatics m

community-care delivery mod - • Northwestern Memorial Hos - a t

els, nursing governance and tive aimed at promoting UK pital: The connected patient i o

adoption, interprofessional com - nurses’ role in implementing • Ann & Robert H. Lurie Chil - n

munication tools, and patient and using information technolo - dren’s Hospital of Chicago: S portals. gy (IT). Technology architecture and y s

Now is the time to share prac - A hosted nursing-leadership design. t e

tices in nursing informatics delegation trip to Chicago culmi - m

globally. This is essential to the nated the initiative. A 10-person Emerging ideas s success of the journey toward delegation of nursing informat - Introduction of robust and so - health information technology ics leaders was selected from phisticated clinical information (HIT)-enabled transformation. across the UK to meet with U.S. systems has prompted signifi - Although many nurses might nursing informatics leaders, visit cant transformation in health focus on differences in payment key U.S. healthcare facilities that care and focused greater atten - models and delivery methods use nursing informatics to deliv - tion on and out - between the United States and er care, and meet with other comes. Healthcare systems are the UK, significant commonali - providers, suppliers, and govern - under increasing pressure to ties and experiences exist that ment leaders. The delegation ex - improve efficiency while stan - each country can share with the plored innovative technology, dardizing and streamlining other. These were explored in met with nurse executives, and organizational processes and June 2013 by a group of UK spoke with nursing informatics maintaining high-quality care. nursing leaders who visited the United States. Understanding the Magnet Recognition Program® Nursing informatics immersion study The Magnet Recognition Program® is an international organizational credential The 2013 UK Nursing Informat - granted by the American Nurses Credentialing Center that recognizes nursing ics (UK NI) Leadership U.S. Im - excellence in healthcare organizations. It’s based on research indicating that creating a positive professional practice environment for nurses leads to mersion Study was a joint effort improved outcomes for patients and staff. Standards for obtaining Magnet by the Healthcare Information Recognition® are based on research. Components of the Magnet® Model and Management Systems Socie - include: transformational leadership; structural empowerment; exemplary ty (HIMSS), HIMSS Europe, and professional practice; new knowledge, , and improvements; and Cerner Corporation. These part - empirical outcomes. ners launched a year-long initia -

www.AmericanNurseToday.com November 2013 American Nurse Today SR5 s The current knowledge explo - m sion in requires cli - e Delegates’ comments t nicians to learn about and inte - s Delegates from the United Kingdom Nursing Informatics Leadership U.S. y grate information systems into

S Immersion Study made the following observations during their visit to three

their already demanding daily n practice. American healthcare facilities: o i As part of the nursing infor - t Informatics is taken very seriously across all levels of this organization and is a matics immersion study, several integral to care delivery. Nurses are fully engaged in the process. m key concepts common to both “ r Informatics, safety, quality, process change, education, and research were all o the U.S. and UK nursing profes - “ f pulled together into one nursing department.

n sions emerged. These include

I “ a culture of inquiry, shared gov - If you separate technology from the norma“l clinical practice of nursing teams d ernance and accountability and put it on top of the nurses’ normal workload, you’re doomed to fail. n “ a

throughout the organization, , “ y visible nursing leadership, and g real-time data reporting through ment. Professional practice flour - mation to keep up with tech - o l the use of quality dashboards. ishes under influential leader - nology. Another key finding o

n ship, creating an environment was that supporting leadership h Culture of inquiry where innovation is encouraged, roles, such as chief clinical c

e Working closely with bedside cli - adopted, and sustained. Al - information (CCIO), T

, nicians and the IT department, though the three organizations CMIO, and CNIO, champion g the nursing informatics team is the delegation visited had differ - the clinical voice and bridge n i responsible for development, im - ent leadership models, an under - the gap between the IT depart - s

r plementation, and support of lying theme was the need for a ment and clinical staff. (See u new systems. It’s also instrumen - clinical leader, such as chief Delegates’ comments .) N

: tal in fostering a culture of in - medical information officer Clinical transformation is a T

R quiry among the workforce. Giv - (CMIO), chief nursing informa - continuous process that involves

O ing frontline staff access to data tion officer (CNIO), or director of assessing and continually im - P

E provides a scholarly approach to informatics. Nursing informatics proving the way patient care is R change and transformation that leadership is integral to help pro - delivered at all levels. It occurs L

A emphasizes evidence-based prac - mote and drive the organiza - when an organization rejects ex - I

C tices and research. tion’s clinical vision and provide isting practice patterns that de - E

P the underpinnings for a success - liver inefficient or less-effective S Shared governance and ful roadmap. results and instead embraces the accountability common goals of patient safety, The shared governance model Real-time data reporting improved clinical outcomes, and gives clinical nurses a voice in with quality dashboards quality care through process determining nursing practice, Quality data are informing prac - redesign and implementation. standards, and quality of care. tice at the bedside through real- By effectively blending people, This empowers nurses to use time dashboards at each facility. processes, and technology, clini - their clinical knowledge and ex - The electronic systems were de - cal transformation occurs across pertise to develop, direct, and signed to monitor and capture facilities, departments, and clini - sustain their professional prac - adherence to indicators required cal fields of expertise. Constant tice. Interprofessional councils by government and nursing measurement and analysis of and committees allow the nurs - standards. One of the facilities how practice has developed or ing informatics team to con - had unit-based quality message changed from the point of deliv - tribute to and share accountabil - boards that informed patients ery is crucial for ongoing quality ity for decisions made about and families of monthly quality delivery. Analysis of clinicians’ patient-care delivery. Patients outcomes. workflow is needed to determine also participate in councils to if the current amount of direct bring their unique voice. Key findings care being delivered is enough to The immersion study found provide not only good outcomes Visible nursing leadership that organizations that empow - but also compassionate bedside Presence of fully engaged nurs - er their staff structurally by us - care. n ing leaders with a shared vision ing interprofessional shared- aligns with the Magnet philoso - governance models have the Christel Anderson is director of Clinical Informatics phy and the Magnet model com - capacity and agility to deliver at HIMSS in Chicago. Cathy Patterson is a nurse ponent of structural empower - clinical decisions and transfor - executive at Cerner in London, England.

American Nurse Today Volume 8, Number 11 www.AmericanNurseToday.com SR6 S P E C I How nurses drive rapid electronic records A L R E P O

implementation R T :

Liz Johnson, MS, CPHIMS, FHIMSS, RN-BC, and Dorothy I. DuSold, MA, CPHIMS N u r s

thor Liz Johnson is the executive i n

Nurses in one large leader for IMPACT. Her focus is g ,

n 2010, Tenet Healthcare on maximizing use of the elec - T

launched an aggressive roll - tronic record environment to im - e

healthcare system c

Iout of electronic health prove care, rather than just im - h records (EHRs) at 49 hospitals in plementing clinical systems. A n

are involved at all o 12 states, to be completed by , Johnson is co- l spring 2014—only 4 short years. chair of the implementation o levels of EHR g Although federal meaningful- workgroup of the federal Health y ,

use incentives contributed to our Information Technology Stan - a desire to accelerate the schedule, implementation. dards Committee. In 2010, she n d

the main driver was to improve received the Nursing Informatics I patient care through technology, — Leadership award from the n f achieving both meaningful use Healthcare Information and o r and meaningful care. they would own the “care and Management Systems Society m

To reach this goal, we knew feeding” of the clinical system (HIMSS). She brings both clinical a t

our project, called IMPACT (IM - beyond the go-live date. As a re - and public policy perspectives to i o

proving PAtient CAre through sult, nurses have played, and the project. One-third of John - n

Technology) had to be clinician- continue to play, critical roles at son’s senior directors and half of S driven. We needed to design a all levels, including project and her directors are nurses, provid - y s

repeatable methodology that hospital leadership, standards ing a balance of clinical and t e

targeted sustainment, not imple - and governance, and training technical talent to the leader - m

mentation, as the success crite - and support. ship team. s ria. Our challenge was to in - volve clinicians at all levels of Project leadership Hospital leadership the organization in planning As Tenet’s vice president of ap - Every Tenet hospital has a clini - and implementing the EHR so plied clinical informatics, au - cal informatics director—a nurse

www.AmericanNurseToday.com November 2013 American Nurse Today SR7 s who serves as the clinical leader EHR training and ongoing sup - informatics directors. m during EHR implementation and port throughout the organiza - Since the inception of IMPACT, e t acts as clinical guardian for tion. At the hospital level, nurses we’ve hosted three clinical infor - s

y post-implementation system and fill most of the training and “su - matics academies, providing S

workflow optimization. Each per-user” roles during EHR imple - continuing education credits to n hospital’s chief nursing officer mentation to prepare colleagues. more than 70 nurses. We’ve also o i (CNO) leads the multidiscipli - After implementation, many con - developed a skills assessment to t a nary clinical-process improve - tinue their roles to provide new provide guidance to clinical in - m ment committee that defines employee training, refresher ses - formatics directors in their de - r

o new workflow, policies, and pro - sions, and support during clinical velopment and performance. f

n cedures to improve efficiency in system upgrades, enhancements, Recently, we conducted a behav - I the electronic environment. In or added functionality. At the en - ioral analysis of our clinical in - d many Tenet hospitals, the CNO terprise level, nurses account for formatics population and identi - n a

also serves as the hospital exec - a high percentage of our clinical fied the “behavioral DNA” of , y utive sponsor for IMPACT, pro - support teams, including a spe - our top performers. g viding the drive and sense of ur - cial clinical help desk that serves Tenet nurses are playing a o l gency to the organization. . critical strategic role in en - o

n abling rapid EHR implementa - h Standards and governance tion across our . c e To realize the full benefits of the Tenet’s EHR project has led They’ve had a tremendous in - T

, EHR, our organization recog - fluence on the continuous im - g nized the importance of devel - to new career-development provement of our repeatable n i oping and maintaining the clin - EHR implementation methodol - s opportunities for nurses r ical standards that are used ogy, which accounts for our u across our hospitals. As EHR im - ability to sustain an aggressive

N within the organization.

: plementations reach a critical rapid rollout schedule across a T

R mass, this will enable us to Many nurses continue to large enterprise. We conduct O mine the data in a meaningful formal “lessons learned” ses - P

E way, identifying opportunities to provide post-implementation sions after each hospital imple - R improve patient safety and gain mentation and incorporate L optimization and new A efficiencies. follow-up actions in our I

C Nurses play a key role in methodology for future imple - E functionality design.

P defining these clinical standards. mentations. Because of such

S They participate in clinical advi - feedback, our 2013 hospital im - sory teams with other clinicians Tenet’s EHR project has led to plementations achieved higher to set the standards embedded in new career-development opportu - performance in such areas as the EHR. Hospital nursing repre - nities for nurses within the organ - computerized provider order sentatives collaborate with re - ization. Many nurses continue entry use and online medica - gional and national nursing to provide post-implementation tion reconciliation use, com - leaders on the nursing advisory optimization and new function - pared to initial hospital imple - team. Nurses also participate in ality design. The most significant mentations. Our nurses are the clinical leadership council, addition to Tenet’s core compe - involved at all levels of the comprising chairs of all advisory tencies is the creation of a clini - project implementation, as well teams, to approve standards that cal informatics director position as the ongoing operational sup - cross multiple disciplines. In ad - at each of its 49 hospitals. Nurs - port systems. n dition, teams of nurses are re - es in this role represent all clini - sponsible for translating clinical cal disciplines, ensuring align - Selected references standards into clinical system ment of workflow and practices Johnson L, DuSold D. Driving change designs that are built into the across the continuum of care through clinical informatics. Paper present - ed at: ANIA-Caring; 2012; Orlando, FL. EHR. Each team specializes in within each hospital. They also different aspects of the system, serve as change agents and are Johnson L, DuSold D. The purpose-driven clinical informatics leader: A behavioral such as , emergency de - educated on the principles of be - analysis. Poster presented at ANIA-Caring; partment, , perioperative havioral-change management, 2013; San Antonio, TX. services, general nursing, orders, following a formal methodology. and others. The organization has developed The authors work at Tenet Healthcare Corporation a formal clinical informatics pro - in Dallas. Liz Johnson is vice president of Applied Training and support gram to recruit, educate, and Clinical Informatics. Dorothy I. DuSold is senior Nurses play a significant role in continuously mentor our clinical director of Applied Clinical Informatics.

American Nurse Today Volume 8, Number 11 www.AmericanNurseToday.com SR8 S P E C I How electronic health records are A L R E P O

improving health care for elderly patients R T :

Barb Duffey-Rosenstein, RN, MSc, and Samir K. Sinha, MD, DPhil, FRCPC N u r s

helps coordinate patient care in i n

Innovative real time. Development of a real- g ,

lder adults account for time ACE report providing the lo - T

more than one-third of cation of ACE-designated pa - e

information c

Oacute-care hospitaliza - tients across the hospital helps h tions and 58% of hospital days staff identify these patients more n

technology tools help o in Ontario, Canada. Leaders and easily, aids transfer prioritization l staff at Mount Sinai Hospital in to the ACE unit, and allows staff o ensure patients get g Toronto, Ontario, recognized that to initiate best-practice care pro - y ,

the current hospital system was tocols wherever they may be. a designed to meet the needs of a the right care at the n d

younger population, not frail

Linked communication I older adults. To better address the right time. system n f needs of frail older adults, the In addition to these hospital-based o r hospital sought to develop pro - — strategies, point-of-care interven - m

grams and tools that would help tions across the continuum of care a t

caregivers deliver the right care in have been enhanced by the cre - i o

the right place at the right time. ation of an email-notification and n

communication system regarding S

Acute Care for Elders frail community-dwelling patients y s strategy in the Mount Sinai/Community t e

Mount Sinai was able to seam - Care Access Centre (CCAC) Inte - m

lessly implement and enhance its grated Client Care Project (ICCP) s Acute Care for Elders (ACE) strat - and the House Calls program. If egy with its frontline clinicians one of these patients requires an and informatics department, in unscheduled trip to the ED, the part because Cerner Millennium ® cols as quickly as possible so that patient’s arrival in the ED triggers was already established as the consultations with specialists and email notification, promoting hospital’s electronic health allied health providers can begin communication about the pa - record (EHR) platform. The infor - much earlier. tient’s care. matics department staff met fre - ACE also integrates documenta - The goal of this linked com - quently with frontline caregivers tion of key geriatric clinical pro - munication process using secure to understand their needs and cess and outcomes indicators into email is to enable important in - the care they sought to provide. Mount Sinai’s existing clinical doc - formation exchange among clini - Key components of the ACE umentation tools. These indicators cal team members who know the strategy include six evidence- populate the section of patient at different points along based admission order sets (the the health record to better support the care continuum. Ideally, this general ACE unit order set and the care of frail elderly patients information exchange is solution sets for older patients with chron - and help monitor the overall focused, aimed at avoiding hospi - ic obstructive pulmonary disease, quality of care being delivered. talization whenever possible and heart failure, cellulitis, pneumo - Also, a more seamless inte - helping the patient return to the nia, and hip fractures). The ACE grated service delivery model has community as soon as possible. n superset contains several admis - been implemented at several sion order sets and ensures ACE- points in the hospitalization Barb Duffey-Rosenstein is the director of nursing specific protocols are used in the process and within several informatics at Mount Sinai Hospital in Toronto, care of every older patient. They teams. This model promotes ini - Ontario Canada. Samir K. Sinha is the director of also ensure patients receive opti - tiation of appropriate care in the at Mount Sinai and the University Health mal and care proto - (ED) and Network hospitals.

www.AmericanNurseToday.com November 2013 American Nurse Today SR9 s m e t Progress repor t: Electronic health records s y S n o

i and HIT in the United States t a Judy Murphy, RN, FACMI, FHIMSS, FAAN m r o f

n spread use of EHRs and data I Electronic health sharing among EHRs through d hat an exciting time to health information exchange. n a

be a healthcare provider EHRs manage health information

, records, HIT, and y Win the United States. All in ways that are patient centered g types of providers, along with and give all providers the ability o nursing informatics l their patients, are realizing the to better coordinate care, consis - o n power of health information tech - are transforming tently deliver best practices, and h nology (HIT) as a tool to assist reduce errors and readmissions c

e each person’s journey toward bet - that can cost more money and

T American health care.

, ter health and better care at lower leave patients less healthy. g cost. From where I sit in the Office n

i — of the National Coordinator for From silos to s r Health Information Technology, adopt, and meaningfully use cer - interconnectedness u I’m encouraged every day by the tified EHRs. During this transformation from N

: leadership and clinical innova - The program has worked. In disconnected, inefficient, paper- T

R tion occurring across the nation 4 short years, EHR adoption has based “silos” of care delivery to an

O in this time of profound change— risen dramatically. As of July interconnected, interoperable data P

E especially among nurses. 2013, 60% of eligible profession - system driven by EHRs, the impor - R So let’s look at how we got to als (312,072 of 521,600) and 81% tance of nurses and nursing infor - L

A where we are today. Passage of of eligible hospitals (4,051 of matics has become increasingly I

C landmark healthcare reform legis - 5,011) were participating in the evident. For decades, nurses have E

P lation, including the Health Infor - voluntary program and had re - contributed proactively to the de -

S mation Technology for Economic ceived a Medicaid or Medicare velopment, use, and evaluation of and Clinical Health (HITECH) EHR incentive payment for either information systems. Today, they component of the American Re - meeting the meaningful use crite - constitute the largest group of covery and Reinvestment Act in ria or fulfilling the requirements healthcare professionals working in 2009 and the Affordable Care Act for adoption, implementation, or HIT and are integrally involved in (ACA) in 2010, has changed the upgrade of a certified system. EHR selection, implementation, landscape of the U.S. healthcare The Obama Administration and optimization. Nurses serve on industry forever. HITECH encouraged EHR adoption with national committees and initiatives created the Electronic the passage of HITECH in 2009, focused on HIT policy, terminolo - Health Record (EHR) Incen - because EHRs are an integral ele - gy and standards development, tive Program, administered ment to drive healthcare quality health information exchange, and by the Centers for and efficiency improvements and EHR adoption. In their frontline Medicare & Medicaid are foundational to the health - roles, they are having a profound Services and the Office of care delivery and payment re - impact on healthcare quality and the National Coordina - form needed to transform the in - costs, and are serving as leaders in tor for Health Infor - dustry. Thus, EHRs are critical to the effective use of HIT to improve mation Technolo - the broader healthcare improve - the safety, quality, and efficiency gy. The program ment efforts that are part of the of healthcare services. Yes—it’s a provides fi nan - ACA. These efforts—improving remarkable time to be a nurse in cial incentives care coordination, reducing du - the United States. n to eligible pro - plicative tests and procedures, fessionals focusing on high-quality out - Judy Murphy is Deputy National Coordinator for and hospitals comes, and rewarding providers Programs and Policy at the Office of the National that im- for keeping patients healthier— Coordinator for Health Information Technology, U.S. plement, are all made possible by wide - Department of Health and .

American Nurse Today Volume 8, Number 11 www.AmericanNurseToday.com SR10 S P E C I Paperless in the United Kingdom: A L R E P O

National Health Service goal for 2018 R T :

Anne Cooper N u r s

overload. Too often, centralized i n

The National Health data reporting requirements that g ,

urses on the front line of start with the right aims become T care in the National Service must bureaucratic burdens on nurses’ e c

NHealth Service (NHS) of time. NHS England is working h the United Kingdom (UK) are embrace technology with providers through the NHS n acutely aware of the pressures Confederation on the “Busting o l facing the health service. Rising Bureaucracy” campaign to re - o to meet the g demand for services (particularly move duplications and redun - y , emergency services) and a tight challenges it faces. dant data from the system, mak - a financial environment mean we ing sure it captures only the n d

all need to do more with less. data most valuable to improving I

— n We’re also well aware of the outcomes. f impact these pressures place on act of capturing patient informa - Clearly, getting the most from o r our daily jobs and ability to tion on an electronic rather than technology requires investment. m

spend valuable time with pa - paper record means patients’ de - The first aspect is financial: The a t

tients. To maintain a focus on tails and medical history can be government recently released a i o

quality, last year NHS England made available to clinicians at dedicated £100m nursing-tech - n

launched the “Compassion in the point of care easily and accu - nology fund (equivalent to about S

Practice” nursing and midwifery rately. Earlier this year, NHS Eng - $160 million U.S. dollars) to help y s

strategy. This brought together land detailed a vision for making hospitals get the systems they t e

the “6 Cs”—care, compassion, an integrated digital care record need. This is backed up by a m

competence, communication, for each patient available across broader £500m investment in s courage, and commitment—as the NHS—one that reinforces the health technology made avail - the underpinning values of the active role nurses must play in able to acute trusts over 3 years profession. embracing technology to capture to 2015-2016. Given this pressured environ - and share patient information The second investment is a ment, why did UK Health Secre - electronically. professional one. Getting value tary Jeremy Hunt in January set The next step will be for nurses from technology and information out his priority for the NHS to be across the NHS to use this infor - requires training, paperless by 2018? The answer is mation to change and improve strategic planning, simple: Only by embracing tech - the way they work, closing the and an appetite to use nology can the NHS meet the feedback loop on the care health data to improve challenges it faces over the next process. Based on electronic pa - the way we work. It decade and beyond. tient records, the UK govern - will require nurses, While the history of health in - ment’s care.data initiative will , and health formation technology (HIT) in the draw together and link individ - visitors to take on NHS is a complicated one, there’s ual patient information from the leadership no doubt that technology has the across primary, secondary, and challenge across potential to contribute directly to acute-care settings, making it all levels of or- improvements in care. Technolo - available to clinicians, providers, gani zations. n gy can free up nursing time by payers, and patients themselves. digitizing such processes as early This will allow analytical insights Anne Cooper is clinical warning scores, nurse rounding, to be drawn on how all parts of informatics lead (nursing) device integration, digital pens the health system can contribute for NHS England. for the community, and support - to improvements in outcomes. ing communication between cli - However, the NHS must be nicians. What’s more, the simple careful to avoid information www.AmericanNurseToday.com SR11 SPECIAL REPORT : Nursing, Technology, and Information Systems S o h b l ( p ( i s m T a s t s c n o w t c l i o a m w p f s T a T n i f W h T m d e s n y s o h o h N U R i i h h h h o g n f a h h d y r t l e o e e o

o o i e n 1

r e f r

a f a a e e a t h t l a a o K a y r a e

H a o T W A n i t

w a a t e

n o m 2 n m o l o t t y u

m l t

t k t g h n

d

i p p e n n p ) e r h

l s g t t e o r h i

i s s S o s n (

c t

s e e s

’ r o h e

m o a e m

a e e s w I c

t t

s . g e s e n i h , p m e f i a t A p

e l g

i t h t b e T e

h t e

s

s n e

n t e n t o r t

a e P n f e

o T

,

h t a r

c f u t r m

a r n i a

i a e l a i i )

o e i a “

n i I

n t h e r

, h c o t o N g e n e s z o a

t

h t

i n n n e T t k s u

t r c t

e w u s h u e n s i o a t t

t

s

e n o v u

e u i s e i n

r . l a s e e h o r u h

’ a c r s e g t l t , n b s n o s s

e o y s

n i u r e

h w

e o

i i

e

s r s d h

r r

o f n c t

s c r p t a

c e w s g t t

e n w d

p

c g

s t a

i

s r e r o t f r a e i a e

o e

t o u n i l a e s a t

h t

n i t g e , o h l u

h o s

a e c o ,

z r d e p e n t n k o n U

e

h y

c l l o t

p n

c t d i l

s a

l a r a w g r a l s n e b t a s t n

e a

e n

h s o n l

f h s . e f t f c

e

N n s u , m i t a e o h e l r n ” t n

n r r o

f h l p t h r t p

a l n

e r e o

t r e n g

e l o

o c e i u i d o i

n t G l e i : p t

f b a a t q r o i g a s

’ n c e a e t a l a

i e a t t t B g

h e l

. r m u o k u m d o r m b e

S i n ’ g t i

e i t i v

n l i u l d e s

n s t e d r v

k H t y u n b e n a g e W e y e n l r

r

r u b

n e e i d i f

e , f

i , r d o

a o

l e e

) e e g a

n

r

e . e c o

i g t

o

c o g

i

y w

e e e i c , t

i

b e p

T n w s a f

g

n c e

f a

d l c n h a k

e l t t h K

T r g b e n c

r a d a f t u a c

i

x B n r o u i a i i a h

y i y

s

l i e o u h m t e

t o t s e n h

n o e e y r h i r s n l o s u d i f f c n y p g y h u s o l

t t

n

t a s t u r t ’ t l r i i f o f

p c e n

l o t e

i i a c t r a .

s f v

y h o y s e d

s c g a e d

t e s s 2 a o m t c o

e g o

c c i o t y a r

e t o

t n

l

e . v h e

e

t n t “ e r r

e o t

e a t a s r

0 n t o h i t h h t

d e N s r e r t a f t S e e s i r

n e a w h

e a r

e h , a d e

o m h s l a , n

1 g i x o s

i

a e o

o

s

e n a f

c

c l H s l o n

n n u

M r e V f n t a e g f h t o p t t 8 y

d n e i c d

m f r n t h e i a d a h o t h a

e

f i n d e u

g r s o r v e g S v c r H i . y a . e n c n

l

i g n r i g t s f t u s

e n t e e l t e u t e t e

r . e n i o c M c i o - I e . e i o t

- m f h e ” o o i y y c o s c s s o . t o i a s o m n - r s

e w , . e - i e e l

n f I n - l - r R - s -

f - 8 - - ’ N , o i

N , n

F u e f m r i l S e p c t t t d m i d I e 2 T c p o s w q i s m W m i W c A r l m e t m s u o h t t a b o a a o n g n f 0 a e u h r u o

’ t

a i n e f

s a e o f n s p o e u f h h m m l n r l r c 1 c T i n c a T p e g i p r e

e n

l g d a p o n

s r

v k c e e r e i e e a t

1 8 y

h h r m l r g r

r e t p n e o e e d e i c m r d t K

e i e

1 h i t r r . a o o

y

r c f e i e n

i t a t a t

s

o

e e v e s

c

i r c r v t . e v h a t y f I s a a v I

p , r t l t s e a h e i n

n h

n n i o i n r r n

N T p e a h h e

t e

v W a t e m n t n d e g a o n u k e i p m a o s i a t h i

f d

e c e n d

e a e

s a H u e n d i m o t b f p s e o t o u f i t n n e t e

e n e

n

i

o e

h s s t t n

t

n

g t

m u i r e t r t S r h c

r

s y c e ,

c o c q e

n r h u

r

o

— m o a i e f t t f n

o t t a t

r a M r a a t a f e m ’ g e n o h m i t u o a h o s e

f

a a j r d e l h p l s t r o e

r s o a r e h B l a r h e r d

r

t l i i

s n e t n e l t e e e e a

c l e c p

a r e s I c c i o r A m r l c

o r

t t t y n

. p n a T . h e ’ y

p

o m f n s a k t t n r i

o p

d s u , t

s t

s e

i r

i h o d e a

a e

l s

n e a T r s

D a n e a s n u r o w h o a e t

n i e f i a o e , a s s h n e d

n d e t t r c m t M p a d

o n e u d n i r a t

t , a u d i d i

i c t t o t c g

n y a

o ’ a s

e

o t c e l d o i i i S

h a

u t n i r p

h

n f o o p e m o h

n o p h f n p t i n

e s

r o t , p i n e r s a l

e n

n a s . w c a n n o c i g i l r U n R

g o e e r t

t c l

n t e

o t e

e r y e e o a n t g I

d G

h o

y e

o m

r

y a o m i e

h e s s i b s c t u

n

i i t s s d v s t

t ,

r N e j e

i l a o

’ s h

. t g

h a o

s t t s i e a s s g n s

n o h e s t

u a a s

r c

e n a a K , h o t u

e t E

t a o

c r a . e N p e

l c g a p a e d n s o y a i

o n r t y e n

i t a o o x t t n

v t k m l d n T i i s e s y t h r r

e f H - i u

s p . f

n s n p d . . h e

d f t

- f n t c e m h d . p

u r c . e

c

a a e n h p -

g S i

a l e s v - h f

a C

e h s r

r i r i e e

o - a t r i l e . n

i s a l i e n u o i a n r t n n t - i - - h e -

l - g t - y

P a a t b i m a w c m f t m e t t s e o t S m d t b c m W t w r v t e h h t v w c j t t C v F p V t e o c h o w h i e h e h h e e l h i r i e c t a r a i i v i l r r n o o e l r i i i e h s a c a c c r s s

o c

s n o e u a a r t e a o e e e e i h n l s c i e e s l n C T e

c l s m s d t

t i i t s h h n t l n c a e u n t

s t l r i t t u t h n c n b n o i e r p r e i h

a i l . h s e t g i a e

e

s l i i i e e v f n n i f c s

t y s b a e a t n h n n t e s a i n l t g o o

i a g i e t

s s c s a o a T ’ a

e

u i .

a h n e e a t s t

.

m s , i o o d b c y s

w p

e g l h a m l

f n n

l

l t i w n a

c d h t s p

M i a t l A l e t i t o e t o o

.

l l l W e h l t d n a h c c r l

o h t c

h u t b

e o o o i l e e g e s e r

n i c

r s n u v u a S B o

o o

l l s o l s

g a e g i . t w d e t i r y

d w o g g s t s e m e i i . r l c t N h

, ) n i d r

m a n f f h r s l

u

s

n s h n

l

e n e o e

w

e

r i o i y e f f t l c s T

s t

b

q

h d w a w

b

h I c c c d .

t R i i

d s h a I i i e i w

l f

t i d e s

h

c f u p

T e t c c

h o e u c t e c s a i a T a d n n

t r w o y i N s

o s

i T e i t h r h e

i h e e p

e a n a

a e

i

r a c b f f y t o e t o i

e l s l

t u v w

, w

p m i o

n a h a o f o

’ r r a e o i e

c l o p n t o e . t l p l l i d

s M d s p c n f c

i e . e o y t s s

h l r : f

l l A c n r o

c

f v a i b

, n c t

l m r w g

c e e a r a e

i y l

a p e f m s e n o t H

f p r e h m u A e e o l t e e p i i i t d y o w

o h p

a r

n r t

p s

t l t o l y n n a a n r m

A c e e i f r f m m s a i e h j s n s e s

e a u t v

i m

o h r o m r e . l o g e e h a s l a

r d h r t

s c e e

t t l s

a o d

i e i u i l t b m y

r s i t t s v c d a e e r e e c D u e l m e r f s n r i n d s t

i i h e e h h e r w n a

e g s i a o

c t s r

a r d e l s

p e e e k

n n f n n t a e n w s i t n i i

i

p e o r s s e a v h u

t e e

o

o o d n n h s e c i

b c s d ’

n d

N d d t s i

i i c f d i i s l d n t f a

e f

e m p r o k t e e

a s r r s

n o . c h o c o t t l p e c u

o l U U u

i d u s r

i d e n

n i e x l

i g s p i r i n e

p a a n a a l r n t r W g c s t o e i g

s i a c n n r t s e

k r

i K n

p s

a

t p

’ b e e g a a o t e t l r

s e l r o g b

s q i a

b e i u n t n a 2 l i

f i

e i m e e t n i p T

i p t i v e n r . e s h

. o t i l i

n

c c k o e u u r n w i t i o l i r 0

s u r

w

n i

s h p b s s e

d n n r f s s h e e a o n C t t e

c

h e d e d o s r u s o i

t f 1 o .

o r

r h , h o s t e w a d g , s r h n a m a d g n m

u l o l e s

e i b g o l s a r r i

8 r y ( j e y

- w w e o i p - n a e m m

e e e a r s - r a a S - . e - w n n s c ,

d a - - - e s v - d n g e t e t o y t s i i - e t o ’ - m e - . - - s - - S

latent resistance to technology. P E

First things first: Assess existing processes Nurses who can visualize a C I Before we can improve our use of information, we have to acknowledge where change are less afraid of it. A Clinical leaders should be a visi - L we currently get it wrong. When preparing for any change, it’s easy to focus on R

what’s new. For nurses consumed with hectic workloads, this is an understandable ble presence on units, answer - E P

instinct. But that approach misses the chance to step back and assess existing ing questions and ensuring staff O

processes. A poor digitized process is still a poor process. believe their opinions are heard. R T

Instead, the starting point should be to identify how duplicated documents :

Using information to trans - and unnecessary bureaucracy can be removed from the workflow before they’re N

form the quality of care is a ma - u

digitized. Such disruptive innovation isn’t always popular, but it’s essential if jor change for the NHS, but it’s r technology is to drive transformation. s clinically essential. Putting infor - i n

mation at the heart of care may g ,

not be easy, but if we fail to em - T succeed if led by someone the they’re on the journey and how brace the challenge, we’ll fail e c

nursing community respects. To it will benefit patients. our patients—and that’s not an h ensure that nursing is key in the Visibility is crucial to per - option. Instead, we have to seize n transition requires someone who suading skeptics to embrace the information agenda and of - o l can speak the nurse's language change. Even the best-planned fer the strong clinical leadership o g and engage nurses. Ideally, this change processes will encounter it needs. It will succeed only if y ,

person should be a nurse. Com - critics. It may be tempting to nurses are clear about what they a munication and leadership skills defer engaging difficult groups need and step up to the job of n d

matter more than titles. and instead focus initial ener - making it happen. That means I gies on more persuadable col - assuming responsibility for infor - n f Helping nurses embrace leagues. But difficult though it matics leadership rather than o r change is, early engagement is far more hoping someone else does. We m

Nurses need to be persuaded, not effective. Where hostility festers, know our jobs better than any - a t

compelled. We need to acknowl - it grows stronger and risks one, and we understand what i o

edge that change can be unset - spreading. Clinical leaders our patients need. It falls to us to n

tling. That’s why engagement should take the time to under - set new standards in the quality S should be at the heart of the stand nurses’ concerns, schedul - of care. y

n s

process, not an afterthought. ing training early to help allay t e

Talk of code upgrades will cut fears about what’s coming. m Gerry Bolger is nurse lead for Clinical Systems and

little ice on a busy unit. Instead, Establishing simulation units s Information and Communication Technology at nurses need to understand how to demonstrate new technology Imperial HealthCare NHS Trust in London, England. better information will stream - is particularly effective in coun - Fergus Keegan is deputy director of nursing at the line their work, promote more tering Kingston Hospital (UK) NHS Foundation Trust. informed decisions, and release Cathy Patterson is a nurse more time for them to pro - executive at Cerner vide care. Nurses will Limited (UK). be more tolerant of bumps in the journey if they know why

www.AmericanNurseToday.com November 2013 American Nurse Today SR13 s m e t A Case Study: Using Technology to s y S n o

i Build a Culture of Safety t a Deb Zimmermann, DNP, RN, NEA-BC m r o f

n tive teamwork, communication, I An emphasis on a and collaboration. We believe d en years ago, Virginia that by harnessing the knowl - n a

Commonwealth University edge and skills of our people to

, culture of safety and y THealth System (VCUHS) design safe processes and use g embarked on a safety journey technology appropriately, our or - o appropriate use of l with a vision of becoming Ameri - ganization will become more reli - o n ca’s safest health system. The technology help the able and safer for our patients, h goal—zero events of preventable team members, and visitors. c

e harm to patients, employees,

T organization deliver

, and visitors. Behavioral changes g While safety and quality have VCUHS developed a “Safety First n safer and more i been an ever-present part of our Every Day” behavioral change s

r culture, our focus was on compli - strategy to challenge all staff to u ance with state, federal, and efficient health care. think about safety first—all day, N

: Joint Commission regulatory every day. This strategy includes: T —

R standards. We implemented • senior leaders’ commitment to

O processes to meet core measure safety through daily rounding P

E requirements, created a falls pre - horizontally across all existing on clinical units and discus - R vention program, and instituted programs to create a true culture sions with nurses on safety L

A a rapid response team (RRT). of safety. VCUHS decided to im - • recognition of staff members I

C And while we saw each of these plement behavioral expectations by the chief executive officer E

P succeed, we knew we wanted to to prevent errors and manage the for “everyday” safe behavior

S achieve more than just regulato - organization using a high-relia - and error prevention for pre - ry compliance. How could we bility performance model—one venting harm and reporting truly achieve our vision of offer - used successfully by nuclear pow - near misses. More than 140 ing patients the safest health er plants and air-traffic control employees have been recog - care in the nation? systems. To bring our culture of nized since 2008. Safety star In 2008, 5 years into our jour - safety to life, we needed a mix of exemplars are displayed on ney, our leadership team deter - behavioral changes and techni - every computer throughout mined we needed to accelerate cal approaches. Every member of the organization using our the rate of quality and safety im - our organization from the board - screen-saver system, Net Pre - provement. Instead of thinking room to the bedside received edu - senter. More than 12,000 em - vertically, we needed to think cation on safety, reliability, effec - ployees and physicians have completed training on the principles of safety and how to achieve sustainable improve - ments. All nurses are specially trained in all aspects of effec - tive teamwork, communica - tion, and relationship man - agement. The nursing professional practice model provides a foundation of shared governance and sup - ports the values of caring, knowledge, leadership, and collaboration.

American Nurse Today Volume 8, Number 11 www.AmericanNurseToday.com SR14 S

• 50 clinical nurses serving vol - P E

untarily as safety champions Achievements at the 10-year mark C I and providing peer coaching Ten years into our campaign to reach zero events of preventable harm to A on use of safe behavioral and L patients, employees, and visitors, Virginia Commonwealth University Health R

error-prevention strategies System (VCUHS) has achieved great results, thanks to safety-behavioral changes E P

• an innovative 15-minute daily and technical approaches. During the past 4 years, VCUHS has: O conference call that reviews the • reduced mortality by 30% and hospital-acquired infections by 88% R T :

safety status of more than 30 • sustained low rates of hospital-acquired pressure ulcers, restraint use, and falls with injuries N operational areas of the hospi - u

tal. In a roll-call format, every • improved skin integrity rates. r s

area reports on such concerns i

In fact, we’ve seen statistically significant improvements in all 12 of the key n

as patients holding in the safety themes we measure. We expect results to improve even more as the g ,

emergency department, patient

VCUHS culture of safety continues to grow and thrive. T

falls, patients in restraints, or e c

patients on suicide precau - h

tions. Team-member injuries patients’ safety-risk information. critically ill and decompensating n and blood and body fluid ex - Nursing units conduct daily safe - patients and assigns each one a o l posures also are reviewed. This ty huddles and use a safety dash - score. Clinicians and the RRT use o g

15-minute call keeps leaders board as part of their huddles. the information to intervene y ,

connected to frontline opera - For all patients on a unit, the proactively and escalate care. a

tions and focused on safety. dashboard displays on a single The results for the first year are n d

Concerns are addressed imme - screen the key indicators of a pa - remarkable. The RRT uses the da - I diately, and follow-up is report - tient’s care and health status, ta as its compass to guide prioriti - n f

ed to the entire health system such as fall risk; need for physi - zation of our sickest patients. The o r

on the next day’s call. Hun - cal restraints; presence of I.V. RRT doesn’t wait to be called if a m

dreds of staff members partici - lines, urinary catheters, and sur - patient is in distress. Instead, the a t

pate in this call each day. gical drains (all of which in - team accesses the MEWS/PEWS i o

crease the risk of infection); and score on mobile devices and ar - n

Technical approaches any overdue medical orders. rives at the bedside to assess and S

Technology has played a major With this ability to quickly assess intervene—at times, ahead of the y s

role in the ability of VCUHS to at-risk patients, nurses can inter - primary team and nurse. Since t e

provide safer patient care. Every vene before a problem occurs. launching MEWS/PEWS, there has m

day, more than 2.5 million trans - The dashboard is accessed more been a 5% reduction in in-house s actions are processed through our than 300 times daily, and the mortality and a 30% reduction in electronic health record (EHR), core indicators displayed have cardiopulmonary arrests outside powered by Cerner. VCUHS nurs - demonstrated measurable im - the intensive care unit. (See es have documentation available provement. For example, we Achievements at the 10-year mark .) at their fingertips about a pa - have reduced the rates of patient At VCUHS, we consider it an tient’s full continuum of care. falls and falls with injuries by honor and a privilege to care for This saves valuable time and, 50%. The dashboard has led to the citizens of our community. more important, creates a safer organization-wide additional ed - It’s up to us to make sure our environment because nurses can ucation in deep vein thrombosis, work is achieving the outcomes get timely, accurate patient data pressure-ulcer reduction, and use that patients deserve and expect. from all specialty disciplines of physical restraints. Clinicians have always worked across the continuum of care. Perhaps the most exciting ex - hard. Now, we work smarter as Also, recognizing that data ample of effective leveraging of well, partnering with interprofes - must be acted on to achieve bet - technology to improve care is sional colleagues, technology ex - ter outcomes, we’ve implemented our Medical Early Warning Sys - perts and, most important, pa - 653 active EHR alerts to provide tem and Pediatric Early Warning tients to provide efficient and clinical-decision support. The sys - System (MEWS/PEWS). Inspired effective health care and create tem can provide a crosscheck for by one of our critically ill pedi - healthier populations. n nurses, warn about a negative atric patients, we recognized the interaction, or offer need for our nurses and RRT to guidance that could decrease pa - have a real-time monitoring sys - Deb Zimmermann is chief nursing officer and vice president of Patient Care Services at Virginia tient complications. tem that continuously measures Commonwealth University Health System in What’s more, VCUHS nurses patient acuity and severity. Using Richmond, and chair of the American Nurses can view a safety dashboard that information from the EHR, Credentialing Center’s Commission on the Magnet identifies high-risk situations or MEWS/PEWS identifies the most Recognition Program®. www.AmericanNurseToday.com November 2013 American Nurse Today SR15 s m e t Technology, transformation, and the s y S n o

i nursing workforce t a Mark D. Sugrue, RN-BC, CPHIMS, FHIMSS m r o f

n wearing it proudly as a symbol I Nursing informatics of their knowledge and profes - d ntroduction of the stetho - sional standing. But it’s not the n a

scope in the 1800s met great tool itself that has transformed

, professionals are y Iresistance among clinicians, clinical practice. Rather, it’s the g who considered it invasive and effective use of the o ready to lead the l contrary to current clinical in the ears of an experienced o n practice. In 1834, The Times of transformation to a clinician that can distinguish h London quoted a British physi - good sounds from bad and c

e cian’s opinion of the stetho - dramatically affect patient

T technology-enabled

, scope: “That it will ever come outcomes. g into general use, notwithstand - Similarly, in the 21st century, n healthcare i ing its value, is extremely health information technology s

r doubtful because its beneficial (HIT) has met resistance among u application requires much time environment. some clinicians. Nonetheless, N

: and gives a good bit of trouble, it’s fundamentally changing T —

R both to the patient and to the the skills and behaviors re -

O practitioner because its hue and quired in the workplace. No- P

E character are foreign and op - without the aid of a stetho - where is this change more pro - R posed to all our habits and as - scope. The tool has become so found than among the 3.1 L

A sociations.” integrated with their practice million nurses, who make up I

C Today, few clinicians could that most clinicians consider it the largest segment of the U.S. E

P imagine providing clinical care part of their standard uniform, healthcare workforce. S

American Nurse Today Volume 8, Number 11 www.AmericanNurseToday.com SR16 SPECIAL REPORT : Nursing, Technology, and Information Systems , 7 - t s - - e n , - s - e n l - 1 e

n c - s o d y o o o r p t e d a y . y e - e y t t c t R c t i v o - r a

e - e , r y - i - g - p e s l s s e o - n

-

, s i S , g e i n g l

e g b - c e r o t o n s c n c h p s p t t s s s e e y n o t o n

h i s a s n a

h t 1 e

o t i p a

i B d s m - s y n o e R s l s ’ a - e

o .

c c e T t l s a

c n a r g

g

o c d

o n e l a

c s d R e t a o r 2 n i . . r i t r r n f n

i

o I s v o i t . i i c o n l n . a i i c s

e e

i e o r t n e t i c o u c l d

m i E R d n i i e n t t o t - e

e e n c m u i t n e l t t t o t o d i n

e l i l p o a t c n e P o N e s H s

w t o

a

r a n i E o t

t r i d a t n y

a d c a e u p n r e L c a n d r e d e h

o G

n a u o m

a S , a

i i T i h h c a

L u r , R c o n d r c I n e k h l e a p

n d a e a o o

S h t G p t e d

d E u t l h h n i f m g i m c n d s n

o e e

v s s n I m E n I b r q l c I e

o

m a h c T e

c

u r t n

M I e r r t

t c a o n s

a

s

, e

r n f I l

s

r n o a r n e v s h o m m e e o c m s e n a T m

i y y g o ) c t d . s a

G c h i c

r i o e e o l g i H r p t

o o p n r s e e o

k c l s e a

t

o

o g p t r e i

I s g f e a n f k i

t o e f l e i

o t d e t u f c f

s n r o f e T R

p l

c a l t e e e n t o

l r

n

a m d

o r t o c

T i

h t l l o h s v c h o e a m h o n a a i n t , f a e o N l e o i n e e

c C

f E a

l

v t a n o t i

r c

i r

o d

o o o c o

e n e i n c d g r , g e d h e t i e g n H h u

, i f

o n c i v h l o d t

k r s e

s ” c i d e n a e i a m C w t o p t r , G e y t o i c i o

t c

h a h e l r u w a r c t e

r

n f r

u m t n e v r m

s n e t a

h i a i

e g c p

e r I

t v n

r

c f l u s

p o o

t c b r i o i n t c t t a e , a d i

e d t o d , p

o g

t a n a e g

n

d u e o g i e e y h i l i

d n a d

t o e T

a c a s i c s a e o l r e r f r u n h d h e e r l l r G i n d u e e u t c e t r h (

n

g r t e

h n n e w f n e

n f

d a e t a a g

m e l

c y h

c r s a

c i g i t

a o g o i p

c l , t d

e t s g

i l e o l a i q ,

c e u n h g t t e

e

s i i r a

i r c d e l n s a i d

y i d s e

n d e t e e e D v n s t

d d m b e

t h a t t t n i n r

a e o

t r b i e t i n r d r

n

w g h m o p u a m e e n c s

o i r m m t c s t

h c c l h a d A e n i i a s “ e a h u g

t

a e n a

s i i d

e v

a r r

u s

s i s i t

n a i u t t n o t a

l i c t , g r f r n m i h

t u e l T n a s i r i

s n t s

f s o r t h r e n i u a v s

h n r o r t o o c r u a s n

s u n t t

a c l r x r o i i v n n

s m m n i

u i e f

t N I f

e C a e . r

e f e

t P g i a o

a i o

i

t s s i e l e

u

r r s n

e - t o a l e e n a g

p s d d e s a e f a h i o i s W n e . . y 6 d r u s i y

s s s i p e n c s c

h r a a u n

n t e s

o m o o

c c

y i ) e e c o ( c r u r 3

i l n l c u r h m

t c n S . 0 e e i

t f f c r s h c n v l l s R d r

p e y e l o e m p m 1 a e p i u c t i h g z t . t

a r a i i

e s s p e r o - u i u n c a s i c n e

s v a 0 c

o i 0 e r b b a e t

D t i u i a t c o h h i t o u

r

c a r m m e e o d n t e d 2 t n n n v s o g

n 2 e a d

d d s t s n t l m r

s m k N W a a n i t h t v f n r n m n m s a e e l n o

t a s r e e

r s a r r

o n o s a v e a a o o o n o o t e r f n n n d r s n e e e g f r r e a a n r n a e e o o a a o i e e y n d i e i r o i o r o e e n i n n b c a b c s c o a n g l M i I A t b t I w p l M i s c t s f c g t a a a t e m d t o a h c s F f t t e m a c p c m e v o - - r i i y N - n - - k - l l - e s l - t c - , o x - a r i e t w p - c l . e h s l U f s i a e n e t l u t o

i e l

o e c n k

p . b

e n m

e i i h s

r q o u i t n n i p s n

s t

n d d s a i r t h s n o t a o i g m t o h

n r

i h

t c e n a i i

n c t o t

i t n e r h r , u c

w o n

y s o

f r l t r

t

a a i s e

c i s c a e e t o y i

t

e o o

t

b o t a r n ’ c n n

t n c h

h y n d e d m k i

w a a w i i t a e o t e o n e e

r

g

m

l i t a i z f i n d n n s o n s , c t i r i s t y o h e e l o r e i t e a e a l e a w

t l f l n a t m o l n g

a

e

h

e w o

f , o m o c k , t o z u o m d a o v a d g

o t n i i

r d m l n e

d t s n r a r

n

t

g f o a e i r t i n n

h r o n e o e r

s n n e

d i o e h g a s o r o a a c l a f p a e

n o e

d m o c

w f g

a h n

c

s t

t n e s s e t g l n e m o h e n e n c s i o o

r d e t r i e c a g n r v i c c t i n a

i e l p n I v g o A k h

o s f n l e o e n e c n r

a c t e g

i i g r f p i t d . o p a . n

e n r a a e b r o

o y i s t , i i n h t

a n n u n a n , r p

r w r i p c

r g i y e

i i s c t g n o y l h g i

n l l e y u s o y e p c o x s t e — s

n e

i a a l

c s e s a

r

t a i n h d a

e s r a p f v

s t

b s d i t i t c i e

g l e r i a l u d

l i , k

x l u m s t r e t a n c

g n m o n

r m s o l d s a o d E d a e

n

i c n n t o a i g n e r s n i o

t a m e a e T r n n v y d e i d l o e e f i i h h o i n s o t c t p a g i r o i h Y m e h c c f w f t t o a d t o i

l r

s y a s o s e c - e - c , - s - - - - o l t i f n t e i - i - - h s , , r e - t - i v n c s t - f n - d n - t - o , a

n n e - r e i . y s a n - e e o ) r n n r i - t 2 t

s y r

- o n o d s l f s i t i y r l o i c

y A h y r - e c y h c j g t f a S n w a s r s r l o e o g l 9 h u 1 a l a c i o

n r o e h t - t e r e i

s n

c % t a i c g e e e f i c o d e .

e S i

e l l a g l n t c o f c p c 9 g u 1 p n s f o i C h

a s C o c c l k n s r c i p a e a

c s a 2 e r o i c n v i h d y e f a c t l n

a a s

r a a a t i n ,

s i

e t 1

0 “ s r p e s n o i p r i t o

h M

c a i i o l r f

n 4 l g ,

m e

s o r j e d h

s y B 1

n e a

a o t e s

I v u a r s e A s 2

h n c

, i o s

f

c

u e

e p e h

e r f y

l l h — e i

u e s o

f

r

n C d g d t y t 1 s s e s a s .

e r s d l h q r r H

e o d y .

t o t n i r

H e l I

I

o o y e

r u a

s s n M o

s i e y e w c o

u c ” S a s

w 0 W e t a r % n

, ( p

n e r p e o r i p A

l n n t u e

l 1 . a r i c l

e

e c . e n v s z . e

o r c a d f h s

—

l e a u e 2 m s n , 7 n a s l i o g h i o v

a n t c s i r e p

d o t t o a 1 a i p . k t p

c h l s a y

r h s n y i

h

e n n t n o d h

n

i s a

r e

e s e 1 m

t o

l t t t E c a e t w z

i o r t n u c r t u 0 4 e n n t n f i

i b s a a s a t . n e

o m o s

S d o s r i a u i

a n r e w

e 7 u p e m a u a t s

t t h o . y i a o g l i a h l i o e n o 2 r c

0 r

t e c t a o a c

d v i h o d e l n r f r t t o v a s j

s t n , n n i t

S i t 0 a h S t o

i e n p e p

i m a o e c f a

m c c 0

u

t f

a a o t m n e

g t n s e i d

e

t i v

e t s S c o o o a s a u u a 0 m n z c a e g m t i r

r

i m f n t f o f l e k v h o d o 2 i i

r e e l s t

s o i t e n n n a s g

i n n z a p f a n t M S

r

e t r e r g 2 t T r

i t t g o a

s o n s r m o i i i r S

N n e c l I

t e o o e

m e n

e h o n r a r e d m n f

e o i n x o a

f o c

i i l o p i c r l l a a f m n i o t

s e d n m a d

b n a l t o m n i i r f v d M l m t

s i s n a h o r e n g i h a a i H t n i c n n h p r a f n t r o e o o o a

s y e c I r t

i

s t

t

h e w c p i s i e h n a u y a a a

t r s o

n a h

l g e

m m f r

n r f a p l

c m l t

f o r

o a w e

d t t a r f c a m e a m n l e n n n N

u e s

y n a o r g i s r r e c l s

t f , f a

e H f a

g d

o t l o p c i n o g p i a n m r n r s e t e e l

s a

u h d o o a a v s

a

g o e v o o

a i a e a e a

a h f A u I b g

n n t , t a c

l u n r g

t i

b m d n e a m

i l f f r e s a n o i r p r s r d a

t

a l i n n i

, c , c

s t

s s

n o e e h c r t o m i

r

i . s s

o w o d n g

t w

i n w a a d c c m e s n g n e i d a g r h y

i t n g y r e h u

i u y s f i

o a y s r i

s o a i n y e o l

e e r g o h h n l l

t g l n n e g l e t e s t n n s r v s o n t n s a i t r e i f a g c S i S e t t

r r r f g d r p r n y g i

d n e h i

a i i m i l o

e s r h a a

T e i n

i

a a t i e n n b m i i t s s a a T I l m u “ t

a e e e

d f o h e n i t I g e t i s d e i a a

s c c r r n e r s i f . v

m v

a e e e s n s A

u r i

t t d c A

t a n s m

i i i . l v v v

s t t

s o s i h r n i n n n e l c e r o h

y

u c c e r e n i c i c r s e i i i i

l

n

— m s t

o n

t r r d d n l n t l e d w T l e e

i

e

n n l l l l r l l r e

m a a e e e e o g r g f g g g e c e s r

r s s

c c u n n u i a i h

t o o o v f o i o u e u r l n d l n e w r e e e f f a y

i i d x

v a l a a l a o i e o C v h h h h h i i o e o i a e

n n

n c n n l l

n

N i a c c m f s t n a n h c N f T S n n a n o f i t t o t v t S b t a f e i i f p f c a c c d t c s d w e d i w t

o i

l “

e

o r

e

l

a

d

a i

v

z p

t l

a u

i l

n

a

i

e

n

n

a

l

i

p

a

t

t

y

g

n

a

r

a

o

o

d

c

w e y

r

r

e e

v v i

i

l

l

e

e

d d

-

e

r

a

c

s m e t Using technology to make evidence-based s y S n o

i staffing assignments t a Amy Garcia, MSN, RN, and Kate Nell, MA, RN m r o f

n ity is calculated based on the I Workforce- whole patient, including activi - d s military leaders know, ties of daily living; physical, n a

no battle plan survives psychosocial, educational, and

, management y Aits first contact in battle; perceived needs; and family sup - g too many variables exist. The port. The system automatically o software and l same can be said of nurse staff - calculates the staffing levels and o n ing. In health care, the “first operational skill mix needed to help the pa - h contact” occurs when staff mem - tient progress and adjusts the c

e bers call in sick and patient levels based on ADT activity.

T integration help

, numbers or acuity increase or The healthcare team rounds g decrease more than planned. together in the patient room and n match the right nurse i Scheduling and staffing aren’t uses the information obtained to s

r simply a matter of achieving a manage the patient’s care toward u certain ratio; the cost of mistakes to the right patient at a single departure date and time. N

: can be measured both in dollars Carol Wahl, chief nursing officer

T the right time.

R and human lives. Applied tech - (CNO) at CHI’s Good Samaritan

O nology is improving our ability Health Systems in Kearney, Ne - P

E to assemble real-time, actionable — braska, states, “Patient satisfac - R information to support staffing tion has skyrocketed… caregivers L

A decisions and resource alloca - as a resource, and evidence- report that combining care man - I

C tion. New evidence-based soft - based practice for staffing. agement with case management E

P ware computes large amounts of is delivering better, more coordi - S data and applies algorithms that Resource-demand nated patient care.” help match the right nurse to the management right patient at the right time— Catholic Health Initiatives (CHI) Workforce-management and at the right cost. This article has combined technology, busi - solutions describes how nursing leaders ness processes, and a collabora - Midland Memorial Hospital are using and benefiting from tive care management strategy (MMH), a not-for-profit hospital technology that integrates pa - to optimize care delivery and serving northwest Texas, uses tient demand, nursing workforce manage length-of-stay bench - workforce-management technol - marks. A national ogy to optimize the quality of nonprofit health sys - care and control costs. Centering tem based in Colo rado, on a web-based portal for real- it operates nearly 90 time schedule management, the hospitals in 18 states. software is fully integrated with To update each pa - human resources, education, tient’s progress contin - and time and attendance data. uously, CHI uses a so - MMH has automated its sched - lution with real-time uling, established self-scheduling interfaces with the hos - practices, and created a fatigue- pital’s admissions, dis - management guideline. Selected charges, and transfers nursing competencies, such as (ADT); the electronic advanced cardiac life support, health record; and are visible on the staffing page, concurrent coding sys - alerting nurses to keep their li - tems. As nurses docu - censure and certifications active. ment patient care, acu - Nurses can self-schedule into an

American Nurse Today Volume 8, Number 11 www.AmericanNurseToday.com SR18 S open slot only if they meet the whether patient flow, staffing, and shared-governance models to cre - P E requirements of that role. care coordination are operating at ate schedules using systems pro - C I

MMH also uses a patient- equilibrium. “Dashboard” views grammed to account for unit A assignment tool that recognizes display bed management, surgery, characteristics, union contracts, L R

the importance of continuity of emergency department, trans - and labor law. With the aid of this E P

care. The technology helps nurses portation, environmental services, technology, they can fill staffing O and leaders achieve balanced as - and equipment status simultane - gaps and understand the financial R T :

signments while creating an elec - ously in real time. Such integra - impact of moment-to-moment de - N

tronic record of primary and relief tion of operations that previously cisions. They can link demand for u assignments. The nurse leader existed in silos helps staff make care and hours worked to nursing- r s can use drag-and-drop functional - actionable decisions to maximize sensitive quality measures. i n

ity to assign nurses additional du - operational efficiency and clinical Imagine a future where nurs - g , ties, such as crash-cart checks, excellence. ing is reimbursed for the value T narcotics counts, and refrigerator Nursing leaders make decisions nurses bring—where nurses have e c

checks. Transparency of assign - on staffing resources every day, easy access to staffing, patient h ments can change nurses’ percep - but determining if those decisions progress, and financial informa - n tion of the fairness and equity of are good ones can pose a chal - tion; where they maximize tech - o l those assignments (a key compo - lenge. Dan Roberts, associate di - nology to clearly establish the o g nent of nurse satisfaction). rector for nursing at Stony Brook relationships between an invest - y ,

ShiftAlert is an important tool Medicine, a teaching healthcare ment in nursing care and better a that frees up time for staffing system in Long Island, New York, patient outcomes; where they n d

offices and charge nurses, who uses technology to inform the fol - work with the finance officer I typically spend hours each day lowing questions: “Did we maxi - to make the right investment. n f calling nurses to fill gaps in the mize people, processes, and tools? Imagine a future where technol - o r upcoming shift. This system com - Did we have the right patient on ogy helps us match the right m

municates urgent, short-term the right unit with the right plan nurse to the right patient at the a t staffing needs to qualified staff via of care with the right staff doing right time. That future is now. n i o

text messages, email, and interac - the right things?” He comments, n

tive voice response. Using the “These new operational ‘rights’ of Selected references S unit’s supporting business process - nursing point to access, quality, American Nurses Association. ANA’s Princi - y ples for Nurse Staffing . 2nd ed. Silver s es, ShiftAlert first offers the open and cost. If you have these rights t

Spring, Maryland: Author; 2012. e

shift to nurses qualified to work on as a part of your nursing model, m Caspers BA, Pickard B. Value-based resource

that unit who wouldn’t be earning how do you know you have them s management: a model for best value nursing overtime or premium pay. The correct…in real time? These ques - care. Nurs Adm Q . 2013;37(2):95-104. software eases the administrative tions are particularly important as Creating value for patients for business suc - burden of charge nurses, helping governments and payers encour - cess. Leadership . 2011;25-8. www.hfma.org/ them focus more on patients and age reductions in length of stay Content.aspx?id=3685 Accessed September staff development. and tie reimbursement to meas - 24, 2013. The technology MMH uses ures of quality and satisfaction.” Dent R, Bradshaw P. Building the business to optimize the workforce and case for acuity based staffing. Nurs Leader . progress of patient care has 2012;10(2):26-8. www.nurseleader.com/ Systems that provide article/S1541-4612(11)00341-7/abstract. yielded significant returns. Ac - real-time staffing Accessed September 24, 2013. cording to CNO Bob Dent, “The information Garcia A. A patient acuity checklist for the improvements in costs were cap - CHI, MMH, Florida Hospital Sys - digital age. Nurs Manag . 2013;44(8):22-4. tured in the reduction in and tem, and Stony Brook Medicine elimination of high-cost labor, use technologies that provide The authors work at Cerner Clairvia in Kansas City, such as overtime and agency real-time, actionable information Missouri. Amy Garcia is the chief nursing officer usage. At MMH, the return on on safe staffing. These technolo - and Kate Nell is the director. investment for the technology gies give nurses transparency happened within the first year.” about patient acuity, intensity, Nursing Times Learning has produced stability, and progress so they can an online learning unit on nursing doc - Technology that integrates more easily make assignments umentation. “Clinical Record-keeping” operations that take into account continuity features case-based scenarios to help Florida Hospital System, an inte - of care, educational and profes - nurses relate their learning to practice, grated system serving central Flori - sional characteristics, skill mix, and learners can print out a person - da, is installing command centers and work environment. Nurses alised certificate on successful com - ple tion. For more information go to: to serve as operational headquar - can use reports to predict patients’ www.nursingtimes.net/record-keeping . ters where staff can see at a glance needs prospectively and can use

www.AmericanNurseToday.com November 2013 American Nurse Today SR19