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Quality of Electronic Nursing Records the Impact of Educational Interventions During a Hospital Accreditation Process

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Quality of Electronic Nursing Records the Impact of Educational Interventions During a Hospital Accreditation Process CONTINUING EDUCATION ANCC 1.0 CONTACT HOUR Quality of Electronic Nursing Records The Impact of Educational Interventions During a Hospital Accreditation Process Aline Tsuma Gaedke Nomura, MS, RN, Lisiane Pruinelli, PhD, RN, Marcos Barragan da Silva, PhD, RN, Amália de Fátima Lucena, PhD, RN, Miriam de Abreu Almeida, PhD, RN he model adopted for the hospital accreditation Hospital accreditation is a strategy for the pursuit of quality process, based on Joint Commission International of care and safety for patients and professionals. Targeted 1 educational interventions could help support this process. ( JCI) standards, has been an important manage- This study aimed to evaluate the quality of electronic nurs- ment tool. Through the implementation of re- ing records during the hospital accreditation process. A ret- quirements and standards, this process enables rospective study comparing 112 nursing records during the T improvements in quality of care, continuous performance hospital accreditation process was conducted. Educational improvement, and facilitation of educational processes, as interventions were implemented, and records were evalu- well as promoting internal collaboration between depart- ated preintervention and postintervention. Mann-Whitney ments, processes, and team members.2 To achieve the ac- χ2 and tests were used for data analysis. Results showed creditation, several educational interventions are needed that there was a significant improvement in the nursing doc- throughout the institution under review with the aim of com- umentation quality postintervention. When comparing records pliance with JCI requirements. Nursing is one of the areas preintervention and postintervention, results showed a sta- tistically significant difference (P < .001) between the two that needs to meet these requirements, specifically with nurs- periods. The comparison between items showed that most ing records, which is part of the electronic health record scores were significant. Findings indicated that educational (EHR). To meet these requirements, there is a need to incor- interventions performed by nurses led to a positive change porate focused educational interventions, so that nursing that improved nursing documentation and, consequently, documentation can be improved continuously. better care practices. BACKGROUND KEY WORDS: Electronic health records, Hospital accreditation, Nursing audit, Nursing informatics, Quality of TheaccreditationprocessbasedonJCIstandardsisrecog- nursing care nized by many hospitals as a strategy for the pursuit of excellence in quality of care and safety for patients and professionals.1,3 A systematic review of the literature4 identified 26 studies that assessed the impact of the accred- itation process on healthcare. Several of them showed that general accreditation programs were able to significantly improve clinical outcomes and had a significant positive Author Affiliations: Hospital de Clínicas de Porto Alegre (Ms Nomura), Rio Grande do Sul, Brazil; impact on different hospital departments. School of Nursing, University of Minnesota (Dr Pruinelli), Minneapolis, MN; and School of Nurs- There is consistent evidence that shows that accreditation ing, Universidade Federal do Rio Grande do Sul (Drs da Silva, Lucena, and Almeida), Rio Grande do Sul, Brazil. programs may improve the process of care provided by This study was supported by the Research Fund Incentive of the Hospital de Clínicas de Porto health services, which encourages the adoption of accredita- Alegre, Brazil (approval number: 130389). tion programs as a tool with the potential to improve the The authors have disclosed that they have no significant relationships with, or financial interest 4 in, any commercial companies pertaining to this article. quality of health services. Nurses are an integral part of health- Corresponding author: Lisiane Pruinelli, PhD, MS, RN, 1-683 Weaver-Densford Hall, 308 care systems and are critical for health service improvement. Harvard St SE, Minneapolis, MN 55455 ([email protected]). Apreviousstudy5 analyzed the quality of nursing records be- Supplemental digital content is available for this article. Direct URL citations appear in the fore and after the implementation of systematic educational printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.cinjournal.com). interventions. The results showed statistically significant im- 5 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. provement in nursing records after the intervention period. DOI: 10.1097/CIN.0000000000000390 The evaluation was performed using the quality of nursing Volume 36 | Number 3 CIN: Computers, Informatics, Nursing 127 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. CONTINUING EDUCATION diagnoses, interventions, and outcomes (Q-DIO, Brazilian Table 1. Educational Actions Performed by Nurses version),6 an internationally validated instrument to evaluate During the Preparation Period for the Hospital Accreditation nursing records. However, the authors found several limita- Educational Actions tions on the use of the Q-DIO to evaluate nursing records 1. Focus groups based on JCI standards, because the instrument did not cover 2. Systematic meetings with the support groups all of the JCI criteria, and a more comprehensive tool is 3. Theoretical and practical training needed to have a better understanding of the impact of those 4. Lectures for training educational interventions. 5. Clinical case studies The JCI evaluation for hospital accreditation is based on 6. Active and educational visits to the inpatient units 7 standards divided into care and organizational sessions. 7. Implementation of educational evaluations and the establishment These sessions contained 14 items, and 10 of them relate of strategies to fix or alleviate problems encountered directly to nursing records. For this study, nursing records 8. Update of the EHR (specifically updating the nursing are defined as documentation performed electronically by assessment tool with the addition of information related to patient and family’s education and the inclusion of mandatory nurses through nursing assessments, diagnosis, intervention, assessment items) and outcomes. The JCI items directly related to nursing 9. Development of brochures and manuals records are international safety goals of the patient, access 10. Development and review of standard operating procedures to care and its continuity, patient and family right, patient 11. Development of an institutional acronyms list evaluation, patient care, anesthesia and surgery, patient 12. Development of courses in a distance online education format and family education, medicine management, quality im- 13. Printed and electronic informative folders provement, patient safety, and infection control and preven- 14. Availability of a specific space for training, dissemination, and tion. This study aimed to evaluate whether an educational clarification of concerns intervention would improve the quality of nursing re- cords during the hospital accreditation process. To achieve intervention. In addition, there were evaluations of nursing this aim, an instrument, based on the JCI standards, was records in the EHRs on specific topics (eg, pressure ulcer built to evaluate nursing records before and after the [PU], pain), which occurred systematically according to need. intervention period. This need was identified through work groups and visits in the hospital units; when a need for improvement was identi- METHODS fied, additional training was performed. These nurses spent This was a retrospective study that included patients hospi- approximately 300 hours per week on educational actions, talized between 2009 and 2013 in a public teaching institu- including planning, implementation, and evaluation. The tion in southern Brazil. The study was approved by the institutionprovidedanopenspacefortraining,discussion, institutional ethics committee (number 130389). The sample and clarification of specific employee questions and concerns. consisted of 112 records selected from multiple inpatient Although the institution benefited financially for being a units, which contained 52 records from clinical units and public hospital connected to the federal government, em- 60 records from surgical units. This sample size is of suffi- ployees did not receive any direct financial incentives for im- cient power for a 95% confidence level (α = .05). Inclusion proving documentation. Moreover, employees reported no criteria were patients hospitalized for at least 4 days in clini- negative consequences related to the hospital’s compliance cal or surgical units. No exclusion criteria were applied. Data with JCI requirements. collection was carried out from EHRs through the health in- – formation service of the institution. The included records Joint Commission International Specific Quality Criteria were randomly selected, and a proportionate number of re- To evaluate the period before and after the interventions, a – cords were pulled for each year. JCI specific quality criteria ( JCI-SQC) instrument was built. The instrument contained the quality criteria items provided Intervention by the JCI manual measurement elements. Items were mea- The intervention consisted of several educational actions sured on a 3-point scale as follows: 0, noncompliant; 1, partially performed by nurses during the hospital accreditation pro- compliant; and 2, compliant. The instrument contained
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