IPOC: An Interdisciplinary Journey to Improved Care

Holly Bowles RN, BSN, Clinical Informatics Specialist

2013 Statistics

Opened in 1960

281 Bed Community Hospital in North Seattle with

Level 4 ED/Trauma, Level 2 Neonatal Nursery

1900 Employees, 725 Medical Staff

◦ 34,000 ED Visits

◦ 1300 Births

◦ 11,300 Admissions

◦ 450,547 Outpatient Visits

UW Medicine Northwest Hospital & Medical Center

Streamline work and be helpful in patient care

Reduce redundancies in documentation

Ease of use and maintenance of the POC

Care coordination: Interdisciplinary Studies have shown that an interdisciplinary approach to care can assist in

reducing readmissions, mortality, costs and length of stay while simultaneously increasing communication, collaboration and satisfaction of care providers and patients (Preen et al., 2005) (Vazirani, Hays, Shapiro, & Cowan, 2005).

Tool to manage complex patients across multiple admissions Must be evidence-based

NWH Clinical Leadership Vision for Plan of Care Use

Previous process was done on paper

Diagnosis-based

Little interdisciplinary involvement. Plan of Care on the chart was primarily nursing

Protocol based system with pre-printed content. Had the ability to add additional information/variances if needed.

Where we were….

Interdisciplinary group of clinicians:◦ Included representatives from Nursing , RT, PT,

OT, Speech, Care Management, Food & Nutrition and Pharmacy. Nursing’s members included Clinical Nurse Specialists, Clinical Coordinators, Staff Nurses and Managers.

Many meetings and serious work, 2009-2013 Hiatus for CPOE Implementation

How Was the Interdisciplinary Plan of Care Developed for NWH ?

Early Meetings (2009)◦ Encouragement to think outside of the box◦ Hospital was diagnosis-based◦ Evaluated top ICD-9 codes and DRGs and

concluded that it was too large of a number of IPOCs that would be needed

◦ Reviewed NIC/NOC content Used Specialty break downs to help focus the needs

◦ Reviewed Zynx Plans ◦ Decision to proceed with problem-based IPOCs

How Was the Interdisciplinary Plan of Care Developed for NWH ?

Meetings (2013)◦ Started in December 2012◦ Reviewed improved Zynx Plans of Care◦ Reviewed design decisions made in 2009◦ Reviewed list of requested Plans of Care from

2009 Narrowed list down from 135 to 77

◦ Held 3 all day design sessions over 1 month along with “homework” for designated staff Hospital wide IPOCs done with entire group Specialty based IPOCs done individually/small groups

How Was the Interdisciplinary Plan of Care Developed for NWH ?

~THE RESULT~77 INTERDISCIPLINARY PLANS OF

CARE

Interdisciplinary- Therapies, Respiratory Care, Food & Nutrition, Pharmacy, Care Management, Nursing

Problem-based pans Easy access to review, initiate and update Evidence based standards using Zynx Standardized Language: SnoMed CT Protocols are incorporated Clinical Notes are associated with Expected Outcomes Unique Clinical Summary Layout to facilitate both staff

and provider usage Easier to focus attention on the highest priorities for

the patient during this encounter

Where we are now..

Sample IPOC

Clinical Summary Layout

Soarian Clinical NotesTaking us where no Northwest Hospital Staff has gone before…..

Can you tell if this patient is progressing toward Expected Outcomes?

Where we were….

Where we went…

Where is the Progress in this Progress note??

We see some of what the staff did during this shift, but not where the patient is related to their goals….

Documented in Shift AssessmentDocumented in MAKDocumented in VS/I&OWhat does this mean???

Break it down….

How much time are we spending on writing progress notes that duplicate existing charting?

Progress toward or away from Expected Outcomes

Unusual event note- Security issues, family issues, lost belongings

Emergent Codes

ADT notes

Clinical Notes/Progress Notes: When and What?

Chart by exception

Don’t duplicate charting already done

Ask: Should this be captured as a problem?

Writing a good Clinical Note is a skill which takes thought and practice but it will

save time in the long run and our communications will be much improved !

Clinical Notes/Progress Notes

If NWH policy states that we are a “Documentation by exception system”,

Then, we don’t have to do “what we have always done,”

So, let’s take back the clock!

It is time to leverage the power of

technology to improve the quality of care

we are providing for our patients!

One Giant Step…

Workflow Engine listens for clinical assessment documentation, lab test results and signed orders, then suggests patient problems based on clinical data entered in Soarian.

The workflow listens for the initial plan of care save, then sends an alert to the nurse four hours after patient admission, with a reminder to complete the Plan of Care, if not already done.

The workflow monitors for completion of daily Plan of Care Review documentation, and sends a reminder to complete the Plan of Care Review, if not already documented.

After patients are discharged the workflow resolves all active Plan of Care problems.

Workflow in Daily Practice

Training Sessions: 4 hrs. for RNs, 1.5 hrs. for Therapies Training included “hearts & minds” intro, Plan of Care: create/manage,

Clinical Notes, Practice. IPOC Tip Sheet developed at the end of 1st week of post-LIVE support

Training Objectives: Navigate established Plans of Care Manage suggested problems Demonstrate how to develop a Plan of Care, select and add interventions

and chart to outcomes Use predefined evidence-based Plans of Care to individualize patient care Document a clinical note View Standards (original Plan of Care template) View Plan of Care elements and Clinical Notes in Clinical Summary Note: although they work together, Problems, Expected Outcomes and

Interventions are managed separately.

Staff Training

Advertising began with the Clinical Support

Team talking with staff during rounds

Flyers posted throughout the units

“Treats” with labels speaking of Plan of Care

distributed to all clinical staff

Staff Meetings

Weekly Announcements

Getting the Word Out

Staff embraced the IPOCs/Clinical Notes on the first day. The staged roll out planned for 4 days was done in 2! Couldn’t stop them!

Staff became more aware of what they were documenting and questioned processes to stream line their documentation

Staff have commented on time saved, ease of use and how it has brought meaning to the plan of care

Providers became aware of the IPOCs and asked great questions

Clinical Staff Response

Questions?