Nursing's Role in Guiding EHR Implementation to Assure Quality & Patient Safety Marlene McAllister, CNO Sherrill Rhodes, Div Director Quality 2/19/2012 1
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
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
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 402. 2/19/2012 4
West Texas Home of Medical Center Health System 2/19/2012 5
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 1957. 2/19/2012 6
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
2/19/2012 8
Our Journey Background Objective History of Reports Who did what Acceptance by Nurses 2/19/2012 9
How do we go from paper audits to Electronic Reports? 2/19/2012 10
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 2/19/2012 11
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 2/19/2012 12
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 2/19/2012 13
Design participants from: ICU 5W/Pediatrics IT/Informatics Performance Improvement Dialysis 4C 4W 5C 6C 8C 9C ED Nursing Ed Participants Multidisciplinary Focus 2/19/2012 14
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. 2/19/2012 15
What reports are available and how do we use them? VENDOR PARTNERSHIP 2/19/2012 16
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 2/19/2012 17
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 2/19/2012 18
Review of Charting Fields 2/19/2012 19
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 2/19/2012 20
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 2/19/2012 21
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 2/19/2012 22
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 2/19/2012 23
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 2/19/2012 24
Two Automatic Reports to Units 24 hour RN Assessment Daily Nursing Shift Charting 2/19/2012 25
Daily RN Admission Audit Report 2/19/2012 26
Nursing Shift Charting Audit Report 2/19/2012 27
Monthly RN Admission Audit Report 2/19/2012 28
Monthly RN Admission Audit Report Summary Plan of Care Unit 2010_12 2011_01 2011_02 2011_03 2011_04 2011_05 2011_06 2011_07 2011_08 2011_09 2011_10 2011_11 2011_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 2011_01 2011_02 2011_03 2011_04 2011_05 2011_06 2011_07 2011_08 2011_09 2011_10 2011_11 2011_12 2/19/2012 29
Monthly RN Admission Audit Report Summary Percent of Compliance with Documentation upon Admission Admission Chart Audit 2010_12 2011_01 2011_02 2011_03 2011_04 2011_05 2011_06 2011_07 2011_08 2011_09 2011_10 2011_11 2011_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) 2/19/2012 30
RN Admission Audit Report Summary 2/19/2012 31
What s Happening Now!!! Developed of Reports Development of Vendor Reporting Score Cards Development of Care Alerts Review of Reports for each Electronic Implementation 2/19/2012 32
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 2/19/2012 33
Clinical Analytics Other Scorecard Examples 2/19/2012 34
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 2/19/2012 35
Cost avoidance Benefits Categories Quality Satisfaction 2/19/2012 36
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 2/19/2012 37
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 2/19/2012 38
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 2/19/2012 39
Ongoing Education 2/19/2012 40
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!! 2/19/2012 41
Marlene McAllister, RN, MSN CNO mmcallister@echd.org 432-640-2412 Sherrill Rhodes, RN, MSN Div Dir Quality srhodes@echd.org 432-640-1175 2/19/2012 42