EMR Case Study: Clinical Documentation Optimization

WCBF’s 10th Annual Lean Six Sigma and

Process Improvement in Healthcare Summit

May 11, 2011

Julie BaranCertified Six Sigma Master Black Belt

Memorial Hermann Healthcare System

julie.baran@memorialhermann.org

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Julie Baran - Bio

Julie Baran is a Certified Six Sigma Master Black Belt with 20 years of nursing

experience. Julie is originally from Ohio, where she received her Bachelor’s Degree in

Nursing from Bowling Green State University. She worked as a critical care and

invasive cardiology nurse at the Cleveland Clinic for ten years.

In 2001, Julie moved to Houston to work for the Memorial Hermann Healthcare System

and was part of the team that rebuilt the Invasive Cardiology department after it was

destroyed during Tropical Storm Allison. Since then, Julie has worked in nursing

leadership at the Memorial Hermann Texas Medical Center and Southwest hospitals.

Julie achieved her Six Sigma Green Belt in 2005, Black Belt certification in 2008, and

Master Black Belt certification in April, 2011. Julie utilizes her nursing and Six Sigma

experience to work on large, multiple-hospital initiatives. Most recently, she applied her

DFSS skills to develop a new program at Memorial Hermann to train graduate nurses

following graduation and licensure.

Julie lives in Missouri City, Texas with her husband David, and daughters Alison (13)

and Jenna (7). Besides spending time with family, her favorite hobbies include reading,

technological toys, and swimming.

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Who We Are

Serving greater Houston area, 4 million residents

- One quarter of inpatient market share

10 acute care hospitals

- Tertiary academic medical center (800+ beds) with a

children’s hospital, air ambulance, transplant services

- Eight community hospitals located throughout greater Houston

area

- Dedicated heart & vascular infrastructure

Array of rehabilitative, ASC and outpatient services

- 2 inpatient rehab hospitals and multiple sports

medicine/outpatient rehab centers

- 7 ambulatory surgery centers, 16 outpatient imaging centers

2009

System

2010

4 Hospitals

2010

2 Hospitals

2010

2 Hospitals

2005 - 2010

System

Beds (licensed): 3,286

Annual emergency visits: 323,258

Annual deliveries: 21,536

Annual Life Flight air ambulance missions: 3,185

Annual community benefit: $ 330M

Employees: 19,012

Medical staff members: 4,194

Physicians in training: 1,324 (physicians and fellows)

Residency programs: 26

Fellowship programs: 48

4

Quick Stats and Facts

5

EMR History at MHHS

*As of Feb, 2011 only 3.2% of U.S. hospitals have achieved Stage 6 and 1.0% have achieved Stage 7 (complete EMR) - Data from Healthcare Information Management Systems Society AnalyticsTM Database © 2011

EMR introduced at Hermann hospital (beta partner with Cerner)

Technology and business transformation initiative launched to bring all facilities onto one

common platform (Cerner integrated system applications)

Initiative resumes

1996

1997 -

2000

2000

2002 -

2008

Other facility acquisitions, Complex IT structure - patchwork of disparate systems

EMR HIMSS Stage 6* (full deployment of CPOE - Computerized Physician Order Entry) achieved in

3 out of 10 Memorial Hermann facilities2010

Hermann merged with Memorial1997

Standardized system documentation policy replaces facility-based paper policies2009

Tropical Storm Allison caused extensive flood damage to several facilities; funding diverted away

from initiative2001

Clinical Documentation Environment in 2009

Nursing survey results reflecting increasing

dissatisfaction with documentation

Lack of communication and clarity resulting in

growing antagonism between nursing and IT

Leadership concerns with feedback from staff

High priority request from nursing leadership

6

7

Project Charter

Problem StatementAs documentation requirements and

electronic solutions increase, the workflow of

clinical documentation needs to be evaluated.

Steps have been taken to standardize nursing

documentation and meet national guidelines

and standards of care. We have an

opportunity to improve efficiency, quality, and

satisfaction of the documentation process.

Project Scope• Evaluate work flow in Med/Surg, ICU, and

NICU units (NW, SL, SW, & TMC)

• Exclude areas without AC4 (ED, Peri-Op,

Northeast) and specialty areas (TIRR,

Rehab).

Assessment Objectives – by July 10,

2009

1. Voice of the customer assessment

2. Identification of issues (people, process,

technology)

3. Findings & improvement

recommendations

Resources

Executive SponsorsDavid Bradshaw, CIO

Tim Bevelacqua, System Exec/Critical Care

Helen Powers, System Exec/Six Sigma

Business ChampionsSusan Jadlowski, CNO/COO NW

Steven Weber, CNO SL

Brenda Lyon, CNO TMC

Victoria King, CNO SW

Project Core Team

John Cramer, MBB Mentor Kathy Sater, ISD Lead

Brian Banner, BB Julie Baran, BB Lead

Michelle Chang, BB Shanna Harris, MBB

Jessica Kitchens, GB Jackie Wickstrand, MBB

Facility Clinical Experts

Northwest Sugar Land Texas Medical CenterShelita Anderson, Med/Surg, Denise Austin, GB Karen Brumley, Pedi

Peds, Oncology Angela Green, ICU, Delores Corman, Pedi

Aaron Arias, Med/Surg Med/Surg Andy Draper, ISD

Althea Bennett, GB Gail Rose, ISD Brian Graham, Med/Surg

Margaret Geater, ICU Dawn Johantges, ICU

Patricia Leal-Mack, ISD Southwest Kathy Masters, MBB

Melanie Lewis Michelle Rhea, NICU Kathy Sater, ISD

Beverly Edwards, NICU Nancy Schryer

8

Voice of the Customer

We began by reaching out and hearing what you had to say and quickly

learned how eager you were to share your comments with us!

Online SurveysInterview &

Focus Groups

Face-to-Face

Interviews

31 Directors, Managers,

and Executives

1,155 Responses

8 Facilities

135 Staff Nurses

at TMC, NW, and SGL

Over 3,000 comments collected and analyzed

Voice of the CustomerFront-Line Staff

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Face-to-Face Interviews

3 facilities (TMC, SL, NW)

33 Med/Surg, ICU, and NICU units

153 clinicians were interviewed;

138 were RNs

Interviews were done during all

shifts

485 comments & suggestions

Voice of CustomerScope and Approach

Online Survey

Open to all MHHS acute-care

facilities, except NE

Available for 13 days, including 2

weekends

1155 total responses (RNs &

other clinicians)

2549 comments & suggestions

Online Survey & Face-to-Face Interviews, April – May 2009

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Motion Time StudyApproach

4 Facilities

10 Nursing Units

41 Nurses Observed

3 Observers

108 Observation Hours

Observation Details: 4 hour shifts Shifts ranged from 5AM – 9PM Covered change of shift from

night-day and day-night

Motion Time Study, May 2009

12

From Comments to Recommendations

We sorted the comments into distinct

opportunities across unit types and three

categories: People, Process, and

Technology…

…and developed proposed improvement recommendations.

3,000 Comments 1,454 Distinct Opportunities 60 Recommendations

Make It

Better! M/S ICU NICU

PEOPLE

PROCESS

TECH

535 462 457 1454

174

520

256 256 248 760

48 55 71

231 151 138

M/S ICU NICUMax

Count

PEOPLE

PROCESS

TECH

Unit Type Total 58 57 59 60

99

19 19 19

30 29 30

10

19

31

10

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Evaluating theRecommendations

Each recommendation was assigned two scores based on value

and implementation complexity.

The project team assigned the

Complexity score

You assigned the

Value score

PROPOSED RECOMMENDATIONS

#1 __________

#2 __________

#3 __________

#4 __________

#5 __________

…

14

Prioritizing the Recommendations

Recommendations were plotted on a chart based on their

value and complexity scores and a proposed timeline was

developed.

Prioritization

Matrix

Proposed

Timeline

15

Summary Findings

16

Voice of the CustomerHeadlines

“Why so often?”FREQUENCY OF DOCUMENTATION

“Why so much?”AMOUNT OF DOCUMENTATION

“Why so many clicks and screens?”EFFICIENCY OF CHARTING IN THE SYSTEM

“Why so many changes and updates?”TRAINING AND EDUCATION

Success MetricSystem Changes & Updates

Pre Aug ‘09: Within 12 month period, 32 production changes to AC4

documentation system, with as many as 5 updates within a span of 8 days.

Post Aug ‘09: Quarterly updates Exceptions made for emergent, regulatory, safety, and seamless (i.e., cosmetic

non-functional) updates.

Source: News You Can Use Updates; InSite17

August 2009

We observed nurses and assigned their performed tasks

into 6 categories:

Documentation

Care Coordination

Unit Related Functions

Nonclinical Activities

Direct Patient Care

Non-Value Added

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Documentation TimeBy Task Category

The average documentation task takes 1.6

minutes to complete

Half of documentation tasks take less than

1 minute

Longer tasks such as admission or

discharges may take up to 22 minutes

The average direct patient care task takes

2.6 minutes to complete.

Half of direct patient care tasks range from

1.6 minutes to 20 minutes.

Source: Motion Time Study, May 2009

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Time Lag in Charting Tasks

2.4The average hour difference between the time a task is scheduled and the time it

is actually charted.

0

1.2 3.5 53

Time

Lag

(hrs)

Minimum amount

of time difference

25% of the time, the time

lag can take anywhere

from 3.5 to 53 hours

50% of the time, the time

lag is less than 1.2 hours

Source: AC4 System Data, April - May 2009

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Documentation TrendsBy Hour in Shift

1413121110987654321

50

40

30

20

10

0

117

Sa

mp

le M

ea

n

__X=20.51

UCL=30.64

LCL=10.38

1

1

1

1

NW Hospital 3/6/09 AC4 Entries by Normalized Shift Hour

134 110 112 103 110 106 102 73 82 60 65 29 4 '----->

AC4 Entries

Coding

Nurses

The quantity of documentation entries was also analyzed to highlight

trends throughout one shift.

Documentation activity is the

highest during the first 2 hours

of a shift.

Source: AC4 System Data, April / May 2009

21

Recommendations Summit

22

Recommendation “Buckets”

Recommendations were grouped into six buckets

1. Policy (15)

2. Education (11)

3. Leadership (3)

4. Change Management (7)

5. Available Technology (15)

6. Future Technology (9)

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Phase 1 – Aug ’09 (22 recommendations)- Available Technology (7)

- Change Management (2)

- Education (6)

- Policy (7)

Phase 2 – Nov ’09 (23 recommendations)- Available Technology (7)

- Change Management (5)

- Education (5)

- Leadership Decisions (3)

- Policy (3)

Phase 3 – Feb ’10 (1 recommendation)- Policy (1)

Phase 4 – Future TBD (9 recommendations)- Available Technology (1)

- Future Technology (8)

Undetermined (5 recommendations)- Future Technology (1)

- Policy (4)`

Implementation Timeline

ID Task Name

1 PHASE 1 - AUG 09

2

3 PHASE 2 - NOV 09

4

5 PHASE 3 - FEB 10

6

7 PHASE 4 - FUTURE TBD

8

9 UNDETERMINED

12 19 26 2 9 16 23 30 6 13 20 27 4 11 18 25 1 8 15 22 29 6 13 20 27 3 10 17 24 31 7 14 21 28 7 14 21 28 4 11 18 25 2 9 16 23 30 6 13 20 27 4 11

Jul '09 Aug '09 Sep '09 Oct '09 Nov '09 Dec '09 Jan '10 Feb '10 Mar '10 Apr '10 May '10 Jun '10 Jul '10

75% of all recommendations

delivered in first 3 phases (August

2009 through February 2010)

Further analysis revealed these

recommendations were not

feasible at this time

Phase 4 put on hold due to

other system priorities

Phase 1 ImprovementsFocus on Addressing Critical Needs

Before After

Q 2 hour Frequent Nursing

InterventionsFrequent Nursing Interventions task

removed; chart by exception

Q 2 hour Peripheral IV

documentation required

Peripheral IV task removed; now included

in assessment. Other documentation as

needed (chart by exception).

Q 2 hour Safety documentation

(side rails, etc.) required

Safety task removed; now included in

assessment. Other documentation as

needed (chart by exception).

Results: Elimination of redundant and unnecessary

documentation yielded an overall reduction of

10% or 12 tasks per patient per nurse per day.

Frequent AC4 updates; as many

as 5 updates within 8 daysQuarterly updates

24

Clinical Documentation Environment – 1 Year Later

Improve Flow - Removal of redundant fields

Policy Change - Removal of Q2 Hr Frequent Nursing

Interventions (FNI)

54% spend less time documenting

56% chart more effectively

Quarterly bundles

81% are informed of updates and changes

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6 out of 10 nurses noted an increase in overall

satisfaction since the implementation of improvements

Key Success Metrics

Frequency of documentation

Why so often?

Amount of documentation

Why so much?

Efficiency of charting in the

system

Why so many clicks & screens?

Training and Education

Why so many changes &

updates?

AC4 audit of number of repetitive

tasks per patient

Track number of changes over time,

monitor learning management

system for compliance in

completing online education

Survey clinical users following each

bundle release

Evaluate with bundle

implementation

Implemented reporting format with nursing leadership and AC4 PIT Crew

26

27

Closing the Loop

Frequent follow-up with the recommendation action

owners

Monthly report to CNO Council

Maintain SharePoint link with documents and follow-up

Ongoing dialogue with AC4 PIT Crew and super users

Front-line advocates for change

Sharing of best practices

Setting priorities

Evaluating ideas for next steps

Implementation approaches

Vetting effectiveness

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Lessons LearnedCritical Success Factors

Constant communication with all levels

Regular feedback loops and touch points

VOC from front-line through CNO’s

Partnership between ISD, Nursing Leadership, and Six

Sigma

“Moving on from here” mentality;

no blame for past mistakes

Involve front-line staff and

informal nursing leaders

Phased approach and quick

wins

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Questions?