Governance, Design and Optimization of Nursing ...
Transcript of Governance, Design and Optimization of Nursing ...
Connect Care Governance, Design and Optimization of Nursing Documentation Standards in an EHRNursing Improving Patient Outcomes
ScopeThe impact of the AHS Provincial EHR will be felt everywhere that AHS operates, serves and collaborates.
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Timelines Five year Implementation Fall 2019 – Fall 2023
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Clinical Content
Order / Results Components
Advanced Decision Supports
Clinical Documentation
Clinical Inquiry and Evaluation
Patients, Physicians, Nurses, Allied Health
Organizational considerations – provincial programs, quality and safety, strategic initiatives
Enables providers to make the right decision at the right time at point of care
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Health System Management
Outcomes Management
Documentation Management
Orders and Results Management
Medication Management
Encounter Management
Person Manage
ment
What is & Where is Clinical Content?
• Allergies / Problem List• PIEM – SOGI
standards• Lab workflows, results
management • MedRec, eMAR• Orders, Protocols• Assessments /
Progress Notes, etc.• Standardized data sets
for outcomes measurement
• Standardized content across the health system
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Goals for Documentation • Reduce the burden; eliminate duplication• Evidence Informed Best Practice • Adheres to professional and regulatory requirements • Incorporates decision supports – what an opportunity!!!! • Standardized documentation vocabulary across all care settings /
continuum • Standardized “Scales, Scores and Tools” across all providers / care
settings / continuum• Standardized “Core” set of standards (used by all) and layer on
“Specialty” standards • Supports Collaborative Care and Patient and Family Centered Care
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1. Create the Foundation
Outline and establish clinical governance
Set up projects controls –decision tracking, meeting norms
Establish robust communication processes
Develop outcomes measurement strategy
2. Standardize Processes
Develop principles
Make “Core” (enterprise) decisions
Build off “Core” for specialty decisions
Incorporate eSafety, Human Factors and Intellectual Property Permissions Process
3. Scale Up
Implement
Learn by Doing
Bring different teams together
Consult, Engage and Listen
Solicit information on impact
4. Mature the Approach
Align to strategic directionSupport innovationEnhance decision supports
Support inquiry and self reflection of practice
Refine outcomes measurement strategy
Approach to Standardization – 4 Steps
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• Establish Clinical Governance– For Clinicians by Clinicians – For Patients by Clinicians
• Revisit TOR and membership frequently – Provincial nursing informatics committee was NEW – Over time there is an increase in informatics skill which expands committee scope – With growth and maturity comes changes to responsibilities; take on more
• Document decisions! • Develop outcomes measurement strategy• Make it fun with a committee brand that
everyone is excited about
1. Create the Foundation
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Core Content – Committees Connect Care Content & Standards Committee
Clinical Documentation Committee
Clinical Decision Support Committee
Clinical Improvement Support Committee
Components Committee
Nursing Content Standards Practice Workgroup
Allied Health Content Standards Practice Workgroup
Physician Content Standards Practice Workgroup
Registries Workgroup
Predicative Analytics Workgroup
Clinical Builder Committee
Information Stewardship Committee
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Specialty Content – Area Councils Addictions and Mental
Health Anesthesiology Cancer Capital Management Cardiovascular Services
Continuing Care & Seniors Critical Care Dental Health Child Health Diagnostic Imaging
Lab / Microbiology / Pathology Medicine Neurosciences Financing and Case
Costing
Emergency Medicine (including EMS)
Ambulatory
Primary Care Population & Public Health
Pharmacy Ophthalmology
Transplant & Donor Care Rehabilitation Surgery Renal
Womens Health Others as required
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• Nursing Content Practice Standard Workgroup (NCSPWG)
• First meeting April 17, 2018 • Approximately 50 nurses across multiple specialties and
professions (RN, RPN, LPN) • Set meeting time – every Tuesday am for two hours • Many partners – eSafety, Human Factors, IT,
Professional Associations, Professional Practice, Clinical Content
• Strong Nursing Leadership
NCSPWG
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Role of NCSPWG• Clinical Content – Set the standards and take action to implement• Design – Development and optimization of core/specialty content with system
workflow• Advocacy – Acting as change and communication agents for teams,
programs and sites• Issue Management – Identifying and addressing professional and practice
issues• Risk Management – Identifying risks, impacts and mitigations for a clinical
area• Prioritization – Prioritizing the ongoing CIS requests that is in their realm• Systems Benefits Realization – Measures to track successful
implementation and usage; meeting minimum norm requirements (is the system being used in the way it is intended)
• Practice Standardization (New) – Set the practice standards as a result of technology implementation and take action to implement
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• Develop guiding principles • Make “Core” (enterprise) decisions and stick to
them• Build off “Core” for “Specialty” documentation • Incorporate Human Factors into EHR workflow• Incorporate eSafety & Reporting Learning
System (RLS)• Respect intellectual property - AHS Scale,
Scores and Tools (SST) program
2. Standardize Processes
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Guiding Principles 1. Put patients and families first.
Enhance safety and improve the healthcare experience.
2. Move fast. Make timely, clear and actionable decisions, staying on schedule.
3. Integrate across the care continuum. Favor seamless information flows over niche solutions.
4. Avoid unhelpful variation. Adopt evidence-informed, provincially standardized, guidance and workflows.
5. Adopt and adapt. Express AHS best practice, leveraging vendor content to fill gaps.
6. Use tools for transformation. Do not entrench old inefficiencies in new technologies.
7. Lead with purpose. Maximize engagement of clinical and operational leaders.
8. Partner to advantage. Fully leverage the vendors experience, offerings and relationships.
9. Transform with intent. Monitor and measure expected benefits and unexpected harms.
10. Heed best experience. Collaborate to make the most of your organizations learning and the vendors learnings.
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• Align to project timelines• Implement and move fast; no time to waste• Consult, engage and listen• Solicit information on impact• Success is inclusion and ensure that subject
matter experts come together to collaborate and cooperate
3. Scale Up
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• Learn by doing, be humble and improve• Align to strategic direction – Quality & Safety, Choosing Wisely, etc.• Support innovation – nursing knowledge and procedure integration
into EHR (Lippincott) • Enhance decision supports for nursing – opportunity+++• Support inquiry and self reflection of practice • Empower nurses with their own data about their practice and find
opportunities to improve• Refine outcomes measurement strategy
– Evaluating nursing adoption and how they perceive the system works for them– Nursing care and the impact on improving patient outcomes
4. Mature the Approach (Continuous Improvement)
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Admission• Admission Screenings
– Falls Risk – Schmid (Inpatient); FROP-Com (Ambulatory/Home Care); Scott (LTC); Kinder-1 (ED); Fese (Peds)
– ADL and Assistive Devices – Nutrition – Pressure Ulcers – Braden (Adult); Adapted Glamorgan (Peds) – Suicide (Columbia) – Tobacco– Alcohol– Substance – Domestic Violence – ARO Screening – Values and Beliefs
• Discharge Screening – Living arrangements; Complex needs, etc.
• Covid-19 Identification and Symptom Monitoring
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Physical Assessment• Systems Assessment
– Neurological– HEENT– Respiratory– Cardiac– Peripheral Vascular– Integumentary – Musculoskeletal – Gastrointestinal – Genitourinary – Psychosocial
• Within Defined Limits (WDL)• Standard Definition of Defined Limit
– Evidence Informed Best Practice Approach
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Physical Assessment Example • Neurological WDL
– Alert and orientated to person, place, time and situation – Purposeful motor function – Opens eyes spontaneously – Can communicate needs – Follows commands
• If all of these are met and no other exceptions = WDL
– Reduce the Burden of Documentation
• If there is an Exception – document exceptions– Facial Symmetry – Left Facial Drooping
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Managing Care • In/Outs and Vitals Signs
– Early Warning Systems / Pediatric Early Warning System (Predictive Model) – Sepsis in ED (Predictive Model)
• Daily Cares – Decision Supports Incorporated – Precautions / Falls Interventions / Safe Environment / Comfort Interventions – Mobility / Hygiene / Nutrition / Communication / Entertainment
• Evidence Informed Care Plans – General (Adult, Peds & Neo) – Functional Independence – Pressure Injury – Restraints – Falls – Delirium – Suicide / Depression / Elopement
• Standardized Nursing Handover – IDRAW
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Patient Teaching and Discharge • Safe Discharge Checklist
– 3 days prior to discharge– 1 day prior to discharge – Day of discharge – At discharge – Covid-19 discharge
• Patient Teaching – Standardized: General Education / First Dose Medication / Wound Healing / Falls
Prevention / VTE prevention – Embedded decision supports by linking My Health Alberta Patient Education Handouts – Patient Education Handouts can be printed / sent to patient portal
• Patient Supports – After Visit Summaries provided to patients / available on patient portal – Nurse has a role to include comments on care
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Nurses and the CIS in improving Patient Outcomes
• Patients are taking the initiative to use health technology to be more involved in their care
• The CIS houses the patient story which is available across care settings for everyone on the health care team to see
• Nurses are documenting in the EHR care goals, preferences and what really matters to patients in living with and managing their health issues
• Nurses provide standardized patient teaching and discharge materials in a standardized way and assists patients to better manage their own care
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Successes• Incorporated Evidence Informed Best Practice into documentation • Reduced Burden; if anything we have organized the burden • Avoided duplication and aligned data collection with workflow • Less narrative and more data driven – supports outcomes
measurement • Moved clinicians to accept standardized measures & incorporated
acceptable variance where needed• Reinforced patient safety – standardized clinical information at the
point of care to make decisions (falls, pressure ulcers, etc.) • Created standardized data sets to support self reflection of practice
and provides management with information for health system planning and evaluation of patient outcomes
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Upon Reflection• Rome Was Not Built in a Day! Will Be Built in about Seven Years!• Build outcomes measurement strategy early on
– Nurses satisfaction with CIS; adoption and uptake – Use the documentation data to evaluate impact of nursing care on patient outcomes
• Opportunity to use terminologies for national alignment• Optimize nurses using functionality so get data to evaluate their
care • Emphasis on what matters most to patient care
– Getting back to the premises behind the C-HOBIC Framework – Opportunity to use reporting as a way for nurses to get clinical decision support (spider
graphs)
• Hypothesis and research opportunity: Turning on the System and having nurses use standardized documentation will result in improved patient outcomes (research opportunity)
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