Practicum Project Shadow Charting

Will standardizing the shadow charting process improve nurses satisfaction with the usability of the EHR?

Scope

This project integrated nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice (ANA, 2008).

The scope of this project is to identify if standardization of a process used to support nurses use of the EHR will improve their satisfaction with its usability.

“......such a change can be brought about by improving perceptions regarding the system, specifically perception of the ease of system use and its usability in routine practice. Tailoring interventions that are geared toward understanding nurses’ perceptions will promote adoption (Staggers, 2008).”

Standards

Assessment

Problem & Issue Identification

Outcomes Identification

Planning

Implementation

Evaluation

ANA, 2008

27 hospitals

26 ambulatory surgical/endoscopy centers

3, 534 licensed beds

Research Institute

69 satellite outpatient facilities

4 senior health centers

2 retail pharmacies

19, 736 employees

11,841 nurses 4, 631 physicians

Baylor Health Care System (BHCS) Overview:

BHCS Materials & Website Interviews w/ Stakeholders

Electronic Health Record Implementation Efforts:

Shadow Charting Process OverviewShadow Charting Process Overview:

Part of the optimization effort used in the testing phase of the change request process.

Tests for usability, workflow impact, and education/ training needs prior to implementation of enhancements to the EHR.

Data generated is used to make recommendations to Business Information Systems (BIS) to improve design.

Completing this process is the responsibility of the Informatics Resource Nurses (IRNs).

BHCS Materials & Interviews w/ Stakeholders

Informatics Resource Nurse (IRN) Overview:

The IRN role was established to assess the fit of the EHR to the needs of users.

Intended primary responsibilities are rounding & shadow charting.

IRNs manage the change request process for their facility including implementation of the change.

McCarty, Tyler & Quarterman, 2010

BHCS Materials & Observation, Interviews w/ Stakeholders

Working Relationships of Optimizing Entities:


Problem:

The IRN role and processes, including shadow charting, have not been operationalised with variations at each site.

With variations at each site the data integrity from the shadow charting process is compromised.

Introduction of enhancements to the EHR using this process have negatively impacted users and workflow.

A poor design adds time to the completion of work rather than making it more efficient (Alexander & Staggers, 2009).

Per Chris McCarty up to 99% of communications currently resulting from this process are ineffective and do not reflect the BHCS enterprise model.

Observation, Interviews w/ Stakeholders


Interactive Sociotechnical Analysis (ISTA) Theory

Four key features of ISTA:• The importance of examining actual uses of HIT (“HIT-in-use”), rather than uses that were planned or envisioned by designers or managers.

• The impact on HIT use of technical and physical settings of work.

• Users’ renegotiation and reinterpretation of HIT features.• Interaction and interdependence among social and technical systems and recursive relations among sociotechnical subcomponents.

Harrison, Koppel & Bar Lev, 2007

The five interaction types are:

1 New HIT changes existing social system.

2 Technical & physical infrastructures mediate HIT use—Interaction of new HIT with existing technical and physical conditions affects HIT-in-use.

3 Social system mediates HIT use—Interaction of new HIT with the social system affects HIT-in-use.

4 HIT-in-use changes social system—Interaction of new HIT with the social system affects HIT-in-use, which then further changes the social system.

5 HIT-social system interactions engender HIT redesign—Interaction of new HIT with the social system affects HIT-in-use, which then leads to changes in HIT properties.

Interactive Sociotechnical Analysis (ISTA) Theory


Application of Theory to IRN role & Shadow Charting Process

1. Examination of actual use-IRNs are positioned to interact directly with clinical users. Shadow Charting examines actual use.

2. Observation and Shadowing allow the IRN to take in to account the technical and physical setting in use by nurses.

3. IRNs assess how nurses work around the current system, and how they might work around the change.

4. The sociotechnical components: IRNs determine current methods of communication and how change will affect those methods.


Technography/Ethnography for the study of social–technical configurations(Jansen & Vellema, 2011; Suchman, 1995).

Shadowing...close following over a period of time to investigate people...everyday lives, not what their roles dictate(Quinlan, 2008).

Data grounded in actual events rather than reconstructions (focus group and interviewing)(Quinlan, 2008).

Shadowing suitable to answer questions within complex interrelated processes (Quinlan, 2008).

...”the further removed we are from the work of others, the more simplified, often stereotyped, our view of their work becomes”(Suchman, 1995).

Literature Review

Design of work environment linked to staff and patient safety, efficiency, staff satisfaction, and errors. Excessive cognitive workload.....(Battisto, Pak, Vander Wood & Pilcher, 2009).

Complex Adaptive System. Until redesign ....... frustration, inefficiencies, and suboptimal performance, including error (Vardaman, Cornell & Clancy, 2012).

Critical thinking requires time and control over workflow (Cornell, Riordan,Townsend-Gervis & Mobley, 2011).

Safety items and hand off communication not incorporated into workflow or thinkflow causing workarounds; impede the flow of and easy accessibility of patient information (Sidebottom, Collins, Winden, Knuston & Britt, 2011; Staggers, Clark, Blaz & Kapsandoy, 2011).

Literature Review

Literature Review

“Undesirable outcomes of HIT implementation flow from sociotechnical interactions—the interplay between new HIT and the organization’s existing social and technical systems including their workflows, culture, social interactions, and technologies.” (Harrison, Koppel & Bar Lev, 2007).

“When members of a natural system “perceive collective (at some level) versus individual benefits, they are more willing to participate in and, thus, sustain organizational initiatives” (Winiecki, 2010, p. 36). Solutions that benefit many resonate in the “belief system” of the IRN. Benefits to the collective whole should also be emphasized”

UCD tests validity in the work environment...Ethnographic studies to understand end users and their environment (Narasimhadevara, Radhakrishnan, Leung & Jayakumar, 2008).

(McCarty, Tyler & Quarterman, 2010).

Shadow Charting Model

Receive Request to Shadow Chart IRN IRN Reviews

Request

After discussion with Team Lead and IRN peers is item ready

to be shadow charted?

Return item to design team with

recommendations.No

YES

Is item ready to be

shadow charted?

Yes

Pair up with a buddy and observe their

workflow.

Document in test environment.

Have buddy look over documentation in test environment.

Discuss the change and documentation

with the buddy.

Document and analyze findings.

No

Review findings during team

meetings, with Team Lead.

Send recommendations

to implement or not implement change

Goals & Evaluation.

Core group of IRNs are responsible for educating their peers and revising/updating the process as needed using measurable criteria (i.e. IRN and nurse satisfaction surveys).

Assess nurse(s) and IRNs satisfaction with the shadow charting process immediately after process completion & 1 month after implementation using a likert scale.

Nurse(s) satisfaction with usability will be assessed pre and post implementation using a likert scale.

Checklist for shadow charting process will be used to collect, track, and analyze data. Includes pre and post mapping of nurses workflow, and subjective comments from nurses.

American Nurses Association (2008). Nursing Informatics Scope & Standards of Practice. Silver Spring, MD: Nursebooks.org

Alexander, G.A., & Staggers, N. (2009). A systematic review on the design of clinical technology: Findings and recommendations for future research. Advances in Nursing Science, 32(3), 252-279.

Battisto,D., Pak, R., Vander Wood, M., & Pilcher, J. (2009). Using a task analysis to describe nursing work in acute care patient environments. Journal of Nursing Administration, 42(12), 538-547.

Cornell, P., Riordan, M., Townsend-Gervis, M., & Mobley, R. (2011). Barriers to critical thinking: Workflow interruptions and task switching among nurses. Journal of Nursing Administration, 41(10), 407-414.

Harrison, M., Koppel, R., & Bar Lev, S. (2007). Unintended consequences of information technologies in health care – An interactive sociotechnical analysis. JAMA, 14, 542-549.

Jansen, K., & Vellema, S. (2010). What is technography?. NJAS Wageningen Journal of Life Sciences, 57, 169-177.

References

Quinlan, E. (2008). Conspicuous invisibility: Shadowing as a data collection strategy. Qualitative Inquiry, 14(8), 1480-1499.

Sidebottom, A.C., Collins, B., Winden, T., Knusten, A., & Britt, H.(2011) Reactions of nurses to the use of electronic health record alert features in an inpatient setting. CIN: Computers, Informatics, Nursing, 1-9.

Staggers, N., Clark, L., Blaz, J., & Kapsandoy, S. (2011). Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses’ handoffs on medical and surgical units: Insights from interviews and observations. Health Informatics Journal, 17(3), 209-223.

McCarty, C., Tyler, C., & Quarterman, S. (2010). Baylor Health Care System IRN Competency Based Needs Assessment Final Report. Unpublished manuscript. Optimization Education, BHCS, Dallas, TX.

Narasimhadevara, A., Radhakrishnan, B. L., Leung, B., & Jayakumar, R. (2008). On designing a usable interactive system to support transplant nursing. Journal of Biomedical Informatics, 41, 137-151.

References

Staggers, N., Weir, C., & Pfansalkar, S. (2008). Patient safety and health information technology: Role of Critical Elements of the Electronic Health Record. In R. Hughes (Ed.), Patient Safety & Quality: an Evidence-based Handbook for Nurses (chapter 47). AHRQ Publication No. 07-. Rockville, MD: Agency for Healthcare Research and Quality. E-pub 4/08. Available at: http://www.ahrq.gov/qual/nurseshdbk/docs/StaggersN_PSHIT.pdf. Published, 04/15/2008.

Suchman, L. (1995). Making work visible. Communication of the ACM, 38(9), 56-64.

Vardaman, J.M., Cornell, P.T., & Clancy, T.(2012). Complexity of change in nurse workflows. Journal of Nursing Administration, 39(2), 78-82.

References

Practicum Project Shadow Charting

Documents

Transcript of Practicum Project Shadow Charting