Nursing's Role in Guiding EHR Implementation to Assure Quality & Patient Safety 2/19/2012 1

Transcription

1 Nursing's Role in Guiding EHR Implementation to Assure Quality & Patient Safety Marlene McAllister, CNO Sherrill Rhodes, Div Director Quality 2/19/2012 1

2 Conflict of Interest Disclosure Marlene McAllister, RN, MSN, NEA,BC Sherrill R. Rhodes, RN, MSN, HCAP Has no real or apparent conflicts of interest to report. 2/19/2012 2

3 Session Objectives This session will explore the importance of Nursing, IT, and Performance Improvement working together to assure a EHR implementation that maintains a focus on work flow, successful implementation, adoption, patient safety, and quality outcomes. Session Objectives: Explain challenges and mechanisms used to resolve opportunities Demonstrate how the EHR can be utilized to measure outcomes Provide lessons learned that have supported planning for future implementations 2/19/2012 3

4 Medical Center Health System Medical Center Health System (MCHS) is a full-service regional community academic medical center, with a designated Lead Level III Trauma Center to the residents of Odessa, Texas and the 17-county Permian Basin area. Built in 1949, the original hospital was established with 85 beds and has expanded to its current licensed capacity of /19/2012 4

5 West Texas Home of Medical Center Health System 2/19/2012 5

6 Medical Center Health System Designated Lead Level III Trauma Center Accredited Chest Pain Center Approved Commission on Cancer Program with Commendation 2011: Inpatient Admissions: 14,194 including Rehab admissions Emergency Room: 48,035 patient visits. Labor and Delivery: 1,091 deliveries. 250 Active Medical Staff 500 RNs MCH has maintained accreditation with The Joint Commission on national standards for healthcare quality and safety since /19/2012 6

7 Mission, Vision, I CARE Values High Quality Patient Centered Experience QUALITY Performance Improvement High Reliability Organization PEOPLE Relationship Based Care Reigniting the Spirit of Caring SERVICE Standards of Performance/ Core Behaviors I CARE Advantage Improved Outcomes: Top 10% Quality Measures Core Measures, Readmissions, Mortality; 75 th Percentile HCAHPS, Press Ganey FINANCE GROWTH 2/19/2012 7

8 2/19/2012 8

9 Our Journey Background Objective History of Reports Who did what Acceptance by Nurses 2/19/2012 9

10 How do we go from paper audits to Electronic Reports? 2/19/

11 Why are we here? Executive priorities: 1.Enhance regulatory readiness documentation compliance current patient status/change of shift communication 2.Lay a foundation for analytics reducing reliance on manual chart reviews Increasing time spent analyzing and enhancing care delivery 3.Optimizing value/use of systems 2/19/

12 Incomplete Clinical Documentation? Nurses documenting crucial information in narrative notes versus flow sheets Omitted Regulatory data Braden, Hendrich, pain scales Duplicate items noted in flow sheets, i.e., nail bed color under cardiology and respiratory 2/19/

13 The Timeline October 2008: Mock audit Joint Commission (TJC) readiness needs found November 2008: Optimization assessment October-December 2008: Design of reports January 2009: Deployment (With TJC in the building) February 5, 2009: Full implementation February 2009: Adding a vaccine administration report March 2009: ongoing review of analytics tool needs 2/19/

14 Design participants from: ICU 5W/Pediatrics IT/Informatics Performance Improvement Dialysis 4C 4W 5C 6C 8C 9C ED Nursing Ed Participants Multidisciplinary Focus 2/19/

15 Design Outcomes Clarify definition of complete nursing documentation relative to policy and procedure Must address: Admission assessments Ongoing assessments Pain assessments Restraints Focus areas Acute Care Critical Care Pediatrics Identify key process, policy, and build changes. 2/19/

16 What reports are available and how do we use them? VENDOR PARTNERSHIP 2/19/

17 Currently scheduled Planned next Driving Optimal, Efficient Care Building Blocks Reduction in manual chart reviews; analytics Adoption Deployment Clinical Transformation Optimized technology and process improvement Nurse manager training Nurse messaging, activate changes Re-engineered Processes Stakeholder Involvement Program Alignment Automated reminders for select missing documentation, management reports Design Sessions Policy and Procedures, build alignment, alert and report requirements, Patient-specific views needed Clinical Leadership and Governance 2/19/

18 Two kinds of reports created: RN Admit Assessment Charting Documents that specific patient needs were addressed upon admission Nursing Daily Shift Charting Documents that specific patient needs are addressed each shift 2/19/

19 Review of Charting Fields 2/19/

20 Admission Assessment Report Content Design and Accountability Process Column content tracked/admission: 1. Plan of care documented 2. Braden score 3. Fall risk 4. Abuse 5. Suicide risk 6. Education barriers to learning 7. Education preferences 8. Nutrition 9. Pain acceptable level 10. ADLs 11. Restraints 12. Influenza vaccine 13. Pneumovax 14. Initial assessment done What: Admission Assessment Report (Concurrent) When: Every 12 hours at 4pm/4am, for the previous 24 hrs How: Printed, broadcast agent, charge nurse to pull them off and review prior to shift end for compliance Who:Charge nurse daily and unit manager will verify if they are signed off build into charge nurse evaluation and nurse evaluations What: Admission Assessment Report (Retrospective) When: Every 24 hours at 7am, covers the previous day where assessments should be complete How: Printed, broadcast agent Who: CNO, PI 2/19/

21 Ongoing Assessment Report Content Design and Accountability Process Column content tracked/admission: 1. Plan of care documented 2. Braden score 3. Fall risk/safety 4. Patient Education 5. Nutrition Intake 6. Pain Assessment 7. Bathing 8. Ambulation 9. Catheter care 10. Oral care 11. Shift assessment done 12. Skin assessment 13. I & O What: Admission Assessment Report (Concurrent) When: Every 12 hours at 3pm/3am, for the previous 24 hrs How: Printed, broadcast agent, charge nurse to pull them off and review prior to shift end for compliance Who:Charge nurse daily and unit manager will verify if they are signed off build into charge nurse evaluation and nurse evaluations What: Admission Assessment Report (Retrospective) When: Every 24 hours at 7am, covers the previous day where assessments should be complete How: Printed, broadcast agent Who: CNO, PI 2/19/

22 Restraints Report Content Design and Accountability Process Column content tracked for all patients with restraints applied: 1. Category 2. Kind 3. Order Timestamp 4. Renewal Timestamp 5. Checks Timestamp 6. Plan of Care risk for injury intervention class physical restraint- positive is "perform" What: Restraint Compliance Report (Retrospective) When: Every 12 hours at 7am, covers the previous 12 hours How: Printed, broadcast agent Who: Nurse Managers, CNO, PI What: Restraint Compliance Report (Retrospective) When: Every 12 hours at 7am, covers the previous 12 hours How: Export of data set of episodes of house wide restraints Who: PI, Restraint Team 2/19/

23 Pain Report Content Design and Accountability Process Column content tracked for all patients with pain intervention documented: 1. Patient Name 2. Patient Account Number 3. Time of intervention 4. Pain intervention response 5. Pain scale results- later than the intervention 6. Time of pain scale assessment- not documented What: Pain Compliance Report (Retrospective) When: Every 8am, covers the previous 24 hours-by unit How: Printed, broadcast agent Who: Nurse Manager, CNO, PI 2/19/

24 Training Plan 1. Completed eight 90- minute training sessions Trained 53 people + help desk 2. Training materials Sample reports Report matrix Interpretation guidelines Cross walk from report to specific fields in charting Sign in/attendance Post test and key Staff post test results 2/19/

25 Two Automatic Reports to Units 24 hour RN Assessment Daily Nursing Shift Charting 2/19/

26 Daily RN Admission Audit Report 2/19/

27 Nursing Shift Charting Audit Report 2/19/

28 Monthly RN Admission Audit Report 2/19/

29 Monthly RN Admission Audit Report Summary Plan of Care Unit 2010_ _ _ _ _ _ _ _ _ _ _ _ _12 4C 98% 97% 98% 97% 96% 98% 99% 97% 96% 94% 94% 96% 98% 4W 97% 99% 97% 98% 98% 97% 95% 95% 97% 96% 94% 99% 97% 5C 100% 99% 99% 96% 99% 97% 99% 99% 99% 98% 99% 99% 99% 5W 97% 99% 99% 100% 97% 98% 98% 97% 98% 95% 100% 97% 96% 6C 97% 93% 96% 98% 98% 98% 95% 94% 96% 95% 99% 99% 96% 8C 97% 98% 99% 97% 97% 96% 99% 98% 96% 97% 99% 100% 98% 9C 100% 98% 99% 99% 98% 99% 100% 100% 97% 99% 99% 100% 99% CC 98% 100% 98% 97% 96% 100% 89% 97% 95% 98% 86% 94% 100% CH 99% 96% 99% 99% 97% 99% 98% 97% 97% 100% 96% 95% 97% IN 95% 100% 93% 94% 100% 100% 100% 96% 100% 96% 96% 100% 96% All Units 98% 98% 98% 98% 97% 98% 98% 97% 97% 96% 97% 98% 98% Admission Chart Audits for Plan of Care 100% 98% 98% 98% 98% 97% 98% 98% 97% 97% 96% 97% 98% 98% 90% 80% 70% 60% 50% 2010_ _ _ _ _ _ _ _ _ _ _ _ _12 2/19/

30 Monthly RN Admission Audit Report Summary Percent of Compliance with Documentation upon Admission Admission Chart Audit 2010_ _ _ _ _ _ _ _ _ _ _ _ _12 Plan of Care 98% 98% 98% 98% 97% 98% 98% 97% 97% 96% 97% 98% 98% Braden Score 93% 94% 93% 94% 95% 94% 95% 95% 92% 93% 95% 94% 95% Fall Risk 92% 93% 92% 93% 93% 93% 94% 92% 90% 93% 94% 92% 93% Abuse Screen 90% 91% 89% 92% 92% 91% 91% 90% 88% 87% 89% 89% 89% Suicide Screen 91% 90% 88% 91% 91% 91% 89% 90% 88% 88% 89% 90% 89% Learning Barriers 98% 98% 98% 97% 98% 99% 98% 97% 97% 98% 98% 99% 97% Learning Preferences 89% 88% 87% 88% 90% 87% 86% 87% 87% 85% 86% 86% 85% ADLS (Functional) 99% 100% 99% 100% 99% 99% 99% 100% 99% 100% 99% 99% 99% Restraint 6% 5% 6% 6% 5% 6% 5% 5% 5% 4% 3% 3% 5% Pain assesment 95% 95% 94% 94% 94% 95% 95% 94% 94% 95% 94% 96% 95% (Restraints are Not Required on all Patients) 2/19/

31 RN Admission Audit Report Summary 2/19/

32 What s Happening Now!!! Developed of Reports Development of Vendor Reporting Score Cards Development of Care Alerts Review of Reports for each Electronic Implementation 2/19/

33 Doe, John XXX XXX 0X/0X XX Smith, Suzi Smith, Brenda Smith, Georgia Smith, Georgia Smith, Brenda Smith, Georgia Smith, Georgia Smith, Brenda Smith, Georgia Smith, Georgia Smith, Brenda Smith, Georgia 2/19/

34 Clinical Analytics Other Scorecard Examples 2/19/

35 Reports and Policies Reports RN Admission assessment Vaccine assessment Nursing Shift assessments Restraint documentation Pain documentation Vaccine documentation Policies Updates to pain, restraints, assessments, HED use and WDL New monitoring accountability policy 2/19/

36 Cost avoidance Benefits Categories Quality Satisfaction 2/19/

37 Benefits Soft benefits Failure Mode Effects Analysis (FMEA) Updated policies and procedures/manager training Model for rapid action team Supports TJC continual readiness plan Accelerated benefits realization due to improved data quality Cultural - reinforced accountability and culture of safety 2/19/

38 Benefits Performance Improvement Measurement Plan TJC Documentation Compliance: Baseline compliance (Oct 2008) 55% After Implementation No findings related to documentation compliance February 2009 compliance 85.2% Planned analytics: Automate retrospective analysis compliance Tracking and Trending reports for leaders Pressure Ulcer, Falls, Restraints 2/19/

39 Benefits Hard Savings Service cost (design) - $49,723 Service cost (imp) - $49,508 Est. Training & Education- $10,400 Total $109,631 Cost Avoidance (estimated) 5.5 FTEs $352,352 Estimated FTE Net Savings $242,721 in first year with cost avoidance continuing into future years 2/19/

40 Ongoing Education 2/19/

41 Lessons Learned Importance of Team Work: Executive team, Medical Staff, PI, Nursing, & IT department working closely together Allocate required resources to maintain the system Keep workflow as simple as possible Set realistic goals Communicate!! 2/19/

42 Marlene McAllister, RN, MSN CNO Sherrill Rhodes, RN, MSN Div Dir Quality /19/