The Centers for Medicare and Medicaid Services (CMS) correlates patient satisfaction to quality of care. The organization’s commitment to optimal quality and patient experience requires the involvement of nurse leaders to improve patient outcomes. Nursing leadership regularly round and speak to patients about the environment of care and hospital experience. The traditional pen-and-paper method of leader rounding was an inefficient approach to provide real-time data, quick issue resolution, and flexible reporting.
The organization’s digital solutions team and nursing informatics collaborated on a project request from nursing leadership to design a mobile-responsive web application to capture patient feedback and resolve concerns in real time. The digital rounding solution has a custom-built data collection interface designed to record daily rounding results. Click-to-call and click-to-email functions can be used to report issues to other departments for resolution. Reports can be downloaded in Excel or PDF format and can be sorted and filtered by a broad range of variables. Reports can be used to analyze current usage and bring underlying issues to the surface.
In spring 2018, the quality improvement project was rolled out to a small group of beta users at one hospital location. Over the duration of a year, the nurse managers contributed feedback to improve the application’s functionality and user experience. Data collection and reporting were enhanced based on beta user feedback. The application was deployed enterprise-wide in summer 2019. Nursing informatics provided onsite support which included hands on training.
By allowing nurse leaders to utilize a digital application, the initiative enabled the leaders to prioritize response and identify improvement opportunities. Upon examination of three months of data, comparing rounding results and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores at two hospital locations comparatively equal in size, a correlation is seen between consistency of daily rounding and improvement of HCAHPS scores. Similarly, a correlation is seen between greater executive involvement in the review of weekly rounding results and higher HCAHPS scores. In one observed hospital location, HCAHPS domain responsiveness of staff increased by 5% with 85% utilization and high leadership involvement. Comparatively, this measure increased by only 0.6% in a location with 20% utilization and less reported leadership involvement.
The highest level of improvement in HCAHPS scores have been seen in locations where the availability of a mobile technology for daily rounding data collection has been accompanied by a high level of executive engagement in a reporting model that encourages and reinforces adoption. Ongoing data collection and performance will be monitored and analyzed to continually improve patient experience and quality of care. Digital rounding application is an innovative tool that empowers nurse leaders to use transformational qualities and lead positive and sustaining change.
The nurse chemotherapy administration process varied greatly across a recently formed urban healthcare system. In addition to variance in nursing workflows, the following documentation issues were noted: 1) Inconsistent EMR (electronic medical record) documentation of the chemotherapy administration process in multiple flowsheet versions and note formats. 2) Fragmented, missing, and hard-to-locate documentation which did not present a clear picture of the patient’s care, particularly when treatment was administered at more than one site. 3) A lack of documented evidence of alignment to ONS (Oncology Nurse Society) chemotherapy administration standards. 4) Customization of multiple EMR tools that were not being updated with system upgrades.
An informatics nurse specialist (INS)-led workgroup was convened with oncology nurse clinicians from all system sites for the purpose of aligning the nurse chemotherapy administration process and moving the system to a single EMR documentation instance for this workflow. The workgroup met weekly for a period of 4 months. Each ONS chemotherapy administration standard was examined by the workgroup and both nursing process and documentation standardization recommendations were generated and operationalized.
Deliverables from this workgroup included:
• A standardized nurse chemotherapy administration workflow was developed, and recommendations for operationalizing this workflow were disseminated to all sites.
• A standard chemotherapy administration process document to be used by the system as a clinical resource for practice guidance, clinician training and competencies, regulatory compliance, and reference in site and system policies.
• A series of EMR changes which were approved by the system oncology, hospital, and nursing collaboratives (HSC) to align all chemotherapy nurse documentation and assessment tool versions.
o Adjustment of the MAR (medication administration record) documentation to reflect best practice dual verification workflow and subsequent medication administration for injectable chemotherapy.
o Three independent chemotherapy review documentation processes were reduced to a single process and EMR location. Documentation verbiage was changed to account for physician and pharmacist verifiers where applicable.
o Addition of a documentation field for noting the chemotherapy regimen was verified with the patient prior to administration, per ONS standard requirements.
o Three versions of the CTCAE (common terminology criteria for adverse events) toxicity assessment were reduced a standard single short version of the tool (CTCAEv5). An additional row was added to the CTCAE flowsheet to indicate no toxicities were present on assessment, which facilitated charting by exception.
o Multiple formats of outpatient note documentation were reduced to a single post-chemo infusion note template.
Lessons learned include: 1) Informatics nurses provide effective leadership and direction for clinical workgroups formed to standardize and operationalize workflows, particularly when this occurs in conjunction with design of EMR documentation for those workflows. 2) Validation of newly created documentation with system clinicians ensures the EMR design will support both the system standard nursing process and include the required elements to demonstrate regulatory compliance. 3) Exercising diligence in retiring outdated tool versions as new ones are created avoids more complicated EMR clean up down the road. 4) Minimizing EMR customization facilitates smoother EMR upgrades. 5) Verifying that correct customized tool migration occurred correctly during EMR upgrades avoids unnecessary post-update issues.
Enable front-line clinicians to actively participate in redesign and refresh of electronic health record (EHR) user interfaces, rapid cycle approvals, successful implementation of changes, and more efficient operations.
Prior to this novel structure, a bottleneck in organizational structure caused a backlog of enhancement requests and maintenance tickets for the electronic health record (EHR). Limited input from end users resulted in implementation catastrophes and retracted work. Front-line clinicians were dissatisfied with the EHR and lost trust in the shared governance model. Nursing administration, clinical informatics analysts, and the shared leadership council (SLC) sought to protect time for collaborative EHR design development by direct patient care providers and implement meaningful EHR changes quickly and effectively.
The documentation task force, comprised of multidisciplinary bedside clinicians and various levels of clinical experts, was formed to review EHR enhancement requests and upgrades. This forum provided dedicated work time to fully vet and investigate recommendations and ensure sound decision making on high impact, complex EHR changes. Direct patient care providers contributed design specifications and considered end user impact. Resulting recommendations were presented by front-line clinicians to SLC for final review and approval. The task force dissolved once a recommendation was approved through SLC.
Leveraging a Magnet nursing culture, the task force has driven impactful, desired, and complex redesigns of EHR documentation in areas such as activities of daily living, pain, intake and output, and infection prevention. In the first year, 79% more EHR tickets have been completed and median days to completion has decreased by 88% for enhancement requests. Realized benefits also include early involvement of end users in process improvement, leadership development, promotion of high reliability organizational culture, structural empowerment, and improved adoption of change.
Implementation of an improved intake form, along with the use of a prioritization matrix, enhances understanding of current state workflow and clinical needs. Requiring more detailed specifications and evidence-based references from requestors enables faster approval and prioritization of EHR requests based on organizational goals and regulatory requirements. Active participation and accountability with requestors also increased form completion and satisfaction among clinicians. Impact of this change will be provided at conference time.
The task force model is flexible, inclusionary, meaningful, empowering, and practical. The model has applications in various subjects and areas beyond EHR enhancement and can be used to promote collaborative initiatives between content experts and direct patient care providers.
The clinical excellence (CE) department at New Hanover Regional Medical Center uses data-driven and multidisciplinary methodology to drive sustainable value in terms of quality, cost, and outcomes. Decision support tools within the organization’s clinical information system are recognized as valuable instruments in translating evidence into practice. These tools, specifically order sets, are being transformed to reduce unwarranted care variation and have led to measurable outcome improvements for congestive heart failure and spinal fusion patients. Ongoing work also shows promise in reducing inappropriate blood utilization and improving stroke and sepsis-related outcomes. The purpose of this presentation is to discuss outcome improvements related to the optimization of order sets using evidence-based care standards and decision-support.
Congestive heart failure: congestive heart failure (CHF) is a chronic, progressive disease characterized by high readmission rates. The CE CHF work team used data to identify unwarranted variation in the care of CHF patients. Initial system evaluation revealed that multiple admission order sets were used by various provider groups who admit CHF patients and inconsistent ordering practices among various provider groups. Utilizing a value-based approach to care delivery (value = outcomes/cost), the team revised the order sets to align with evidence-based care standards and support ideal medication utilization and diagnostic ordering.
An initial order set utilization rate of 46.7% during the intervention month increased to and maintained above 91% within four months of implementation and has sustained for over three months through provide-to-provider communication based on utilization reports. Baseline data was aggregated based on CHF DRGs for eight months prior to order set intervention and for seven months following intervention for the following metrics: average inpatient length of stay which decreased from 5.76 days to 5.46 days, all-cause readmission rates which decreased from 19.07% to 16.83%, and average direct cost per case which decreased from $4,895 to $4,469. Additionally, the American Heart Association’s Get with the Guidelines achievement measures composite compliance was monitored during the same time frame and increased from 76% to 86%.
Spinal fusion, blood utilization, stroke and sepsis: Using a similar approach, outcome data was used to identify opportunities for evidence-based order set redesign. Post-implementation data related to spinal fusion has shown an increase in order set utilization from 34% to 90% and a decrease in IV Tylenol and Exparel ordering, both high cost medications with efficacious alternatives, from 45% to 0% and 62% to 35% respectively. Additionally, the post-operative brace ordering workflow was revised, resulting in a year-to-date $33,656 difference in spend from 2018. Blood utilization, stroke, and sepsis work remains in various stages of revision and data will be available for report within the next 6 months. Results from these initiatives will also be included in the presentation.
Clinical decision support has the potential to drive evidence-based care and improve patient and organizational outcomes. While our clinical excellence program is still in its infancy, data supports the positive impact of our work. Learners will become familiar with decision support strategies for order set optimization using evidence to improve outcomes.
Patient safety related to health IT is a significant issue in the US with rapid deployment of electronic health records (EHRs) and other point of care technology. In development of a national strategy to address potential unintended consequences of EHRs, the Office of the National Coordinator for Health IT (ONC) funded and initially deployed a series of assessment and intervention recommendations called the Safety Assurance Factors for EHR Resilience (SAFER) guides. Presently, there is a lack of evidence indicating whether healthcare leaders are aware of the guides and if so, the extent to which these guides have penetrated the healthcare industry. This project will address this gap in evidence through assessment of nursing informatics leaders’ awareness, use, and perceived value of these tools.
The goal of this study is to assess utilization of the SAFER guides by nursing informatics leadership across the country in order to inform strategies to improve their utilization and application. Foundational to an improvement strategy is a thorough assessment of the current state. This project will provide that assessment and make recommendations to national leadership and policy makers on how to improve upon the SAFER guides for their intended purpose. The presentation will report the findings of the national study on the SAFER guides supported by ANIA.
The aims of the study were met by a descriptive exploratory study seeking input from the ANIA membership. The ANIA board of directors invited membership of ANIA to complete the SAFER guides survey, including a demographics survey and a recently developed survey assessing knowledge, value, use, and barriers to use of the SAFER guides. The findings of the study will be utilized to inform improvement strategies and policy recommendations to increase value and use of the SAFER guides.
The aims of the study were to examine the current level of awareness of the SAFER guides among ANIA membership, describe the perceived value of the SAFER guides to the ANIA membership to address patient safety and health IT, evaluate the current use of the SAFER guides, and describe barriers to implementation of the SAFER guides.
Purpose: Nationally, children’s hospitals have mobilized to implement clinical best practices and leverage health information technology to combat what the World Health Organization recognizes as a global threat to children – pediatric sepsis. Researchers estimate 1.2 million cases of children develop sepsis annually around the world. In the United States, sepsis accounts for approximately 75,000 pediatric inpatient admissions a year, with a mortality rate ranging from 5% to 20%. If not promptly identified and treated, pediatric sepsis remains the leading cause of mortality in children, commanding the need for high-reliability, quality improvement work processes.
The project aim was to leverage the electronic health record (EHR) clinical decision support (CDS) tools and best practice models to support early identification of pediatric sepsis, ensure standardization and compliance with treatment guidelines, support practice, improve care delivery, and optimize patient outcomes. This project evaluates the scalable, phased implementation approach to optimizing an electronic infrastructure utilizing data analytics, retrospective case reviews, and interdisciplinary collaboration. The institution examines alert statistical performance analysis to assess changes and improve design. Post-implementation time-to-intervention metrics and patient outcomes are reviewed.
Description: Phase 1 of the project involved modifying the alert/screening criteria (vital sign parameters aligned with evidence-based practice (EBP) and state recommendations), and alert behavior (action-oriented display information, impacted users, and alert lockout behavior) based on data analysis. In phase 2, the project team applied CDS tools to facilitate workflow and practice compliance. Retrospective case reviews and EBP drove changes, resulting in improved case sensitivity. Pre-implementation alert analysis using statistical performance provided predictive screening behavior. Implementation of the sepsis bedside huddle supported best practices to communicate key predictive risk factors among the team.
Evaluation/outcome: The alert data analysis showed an increased alert generation volume and an increased case identification sensitivity to an average of 98% without significantly reducing specificity. In all pediatric units observed, the alert showed an increase in the negative predictive value. In a statistically analysis of 420 cases in the ED, the alert sensitivity increased from 33% to 100%, and a specificity of 92% to 99% after modifications. Alert revisions met the aim of improving sensitivity to support early identification of non-severe sepsis. For non-severe sepsis cases, 100% of cases met the one hour aim of time-to-antibiotics from go-live to May 2019. Greater than 90% of cases met the one hour aim of time-to-fluid-bolus. Both metrics demonstrated a decrease in total turnaround time. Initiatives toward reducing alert fatigue include modification to the inclusion criteria and ongoing analysis of the alert’s statistical performance.
Best practice application, workflow standardization, data analytics, and interdisciplinary collaboration contributed to improved outcome measures. Ongoing surveillance of overall length of stay, mortality, and resource utilization are continued initiatives. The project next steps include analyzing ways to leverage clinical data to generate a predictive score for non-severe pediatrics sepsis and application of the predictive score for risk stratification and early care intervention. Predictive analytics work is needed to optimize recognition, and provide meaningful predictions for at-risk pediatric patients.
Purpose: To decrease patient wait times within an outpatient specialty clinic utilizing event tracking time stamps after educating staff on the new standardized throughput process.
Description: A common concern heard in this clinic by patients and staff is that patients are often not ready to be seen by the physician at their scheduled appointment time. There are long wait times from the time the patient checks into the clinic until they are seen by the provider. Electronic medical record (EMR) event tracking has not been used to help with clinic flow, and overtime was incurred from additional hours worked in the clinic due to throughput issues. As a result, the nursing staff initially started completing manual time tracking on paper, only to realize this was time consuming and time stamps were being missed.
Efficient throughput times in busy ambulatory care medical clinics are an important factor for patient satisfaction, physician satisfaction, and overall staff satisfaction. Capturing data within the electronic medical system and using reporting tools within this system to display the events captured within the department’s patient schedule helped to determine the gaps of patient wait times within the clinic and formulated a plan to reduce these wait times and improve overall satisfaction between patients and staff.
After completing a systematic review of the literature, evidence was found that supported a practice change to track patients from the time they arrive in the clinic until they are ready to be seen by the provider through utilization of the EMR event tracking functionality.
The Rogers Diffusion of Innovations Theory guided the implementation change.
Prior to implementation, staff buy-in was established, education was provided to clinic and float pool staff, and event-tracking report criteria was defined.
Evaluation/outcome: Pre-implementation total encounter visit time averaged 81 total minutes. After implementation, this number reduced to 61 total minutes. After completion of this pilot clinic, other ambulatory care clinics who utilize this EMR have requested and adapted this process change.
In the spirit of transparency, the event-tracking reports are shared with each individual provider weekly by the nurse manager. These reports allow the providers to visualize opportunities for their clinic workflow improvement. Monthly staff meetings are used for analyzing information provided by the reports allowing for collaboration in problem-solving.
Purpose: The surgical safety communication tool was developed in 2015 at the recommendation World Health Organization (WHO). Based on data gathered through extensive consultation, the communication tool aimed to decrease errors and adverse events, increase in teamwork and communication, and provide another layer of safety to our patients throughout their surgical procedure. Furthermore, it was designed to maximize patient safety in the perioperative arena.
It consists of four sections: 1) before operating room: addressed by the RN (pre-op nurse) with patient/patient representative; 2) before induction of anesthesia: addressed by anesthesia provider and RN (circulating nurse); 3) before skin incision: addressed by anesthesia provider, RN, and, surgeon; and 4) before patient leaves OR: addressed by anesthesia provider, RN, and surgeon.
Our organization experienced an increase in incidents involving perioperative processes and surgical communication — specifically, pre-procedure antibiotic administration. This clinical informatics optimization project was proposed in order to increase the use of the surgical safety communication tool in the main OR. The goal was to obtain > 95% documentation compliance for each of the four phases of the tool.
Interventions: A survey was developed and adapted from the system usability scale to assist with gathering information pertaining to the current state of the project, relying on staff observations and interviews. Reasons for the lack of documentation on the tool included the following: inconsistent workflow, as some staff felt they were double documenting; time constraints; difficulty in accessing the device in the operation room; and limited availability of mobile devices when interviewing the patient in the pre-operative area. The intraoperative nursing staff was also responsible for the pre-operative phase of documentation.
Utilizing a business intelligence analytic tool, a baseline data was obtained in August 2019. Information was distilled in the form of poster board education and displayed in the staff lounge area. Education focused on the practice recommendations of the World Health Organization, and regulatory bodies expectations were outlined. Data was obtained daily, and a hard copy was hand-delivered to the manager. Outlined were the members of the nursing staff responsible, as well as a drill-down of the outlier cases. In addition to leadership holding staff accountable, one-on-one follow-up, including follow-up communication via email, was performed with staff during rounding. The A3 problem solving tool was also utilized for the optimization project.
Outcome: There was increased use of the surgical safety communication tool for each of the four phases. Documentation compliance increased from 81.9% to 96.7% among the phases with an average of 95.5%. Incidents involving untimely pre-op antibiotic administration was minimized to zero.
Implication for practice: The WHO (World Health Organization) recommends the use of the surgical safety communication tool as it assists in preventing errors and adverse events, and in promoting patient safety. By monitoring the use of the surgical safety communication tool closely and educating and communicating with staff in order to clear expectations and with leadership holding staff accountable, there should be minimal perioperative incidents, which will ultimately benefit the patient and the organization.
Learning outcome: Outline the steps involved in developing a user-friendly diabetes risk report by collaborating with different stakeholders in the healthcare system for improving diabetes management.
Our health system is an integrated healthcare delivery system and our ambulatory care division is comprised of more than 65 physician practices. Our healthcare system is focused on population health management and diabetes has been identified as one of the most common and expensive chronic diseases in ambulatory care practices.1 Effective diabetes management is time-consuming for providers, and diabetes education cannot be covered in a single follow-up visit. The population health team explored ways to support the providers and clinical staff to be more proactive in identifying and managing high-risk diabetes patients (A1c>9) by utilizing data tools available in EMR. In reviewing existing reports in EMR, no report would identify high-risk diabetes patients. The population health team met with IT to develop a new report. The objective was to combine clinical and behavioral data points to identify patients with a high risk for hospitalization and diabetes-related complications and to develop individualized health goals. Together the population health team and IT agreed on three data points to be included in the report: clinical-focused, compliance-focused and risk-focused. The team added clinical indicators of diabetes (i.e. A1C, BMI, and BP), visit history to identify the visit pattern with a focus on canceled and no-show appointments, and the composite risk score developed by EMR to identify patients with high risk for hospitalization. It has been found that if a patient with diabetes is a no-show to primary care appointments there is an association with increased risk for hospital admissions.2 This report is currently being used in primary care practices to identify high-risk diabetes patients, close gaps in care, and provide education. The report is now being used by the population health team’s newest initiative, health coaches. Health coaches are medical assistants (MAs) and licensed practical nurses (LPNs) who undergo training on various topics concentrated on driving better outcomes in population health. The report was made available to health coaches who team up with providers and identify high-risk diabetes patients. The health coaches use the report to identify patients, do pre-visit planning, close gaps, and support patients to create goals. The health coaches reinforce the patient’s health goals during the visit and follow up with patients later to review the progress of their goals and document and communicate with the healthcare team. Documentation and patient outcomes are displayed in a dashboard where clinical leaders can see the impact the health coaches have on patients with chronic diseases. The report created helped the team to utilize data effectively and efficiently in the population health framework and develop a tool that is accessible to providers and clinical team members, including RNs, LPNs, and medical assistants. The clinical teams have recognized the power of data to manage chronic disease in a population-based approach.
References
1. https://care.diabetesjournals....
2. https://www.ncbi.nlm.nih.gov/p...
Our pediatric institution participates in a national collaborative program to reduce hospital-acquired conditions (HACs). The major goal of this collaborative is to decrease or prevent serious harm related to events that can occur during a patient’s hospital stay. Data from this national organization shows that venous thromboembolism (VTE) is the second greatest contributor of harm throughout pediatric participating organizations. As a participating member of this organization, there were two major components for participation. The first was to identify current rates of this condition and provide accurate reporting. The second, based on their standard evaluation, was to consistently screen patients ≥ 12 years of age and provide the bundle elements of ambulation and sequential compression devices (SCDs). After an initial unsuccessful attempt at instituting this program, a multidisciplinary team was brought together in 2016 to formulate concepts toward establishment of an automated process to capture positive incidence of VTE, as well as a method to prompt staff to screen and provide associated bundle elements. This abstract centers on the implementation of an electronic VTE screening and bundle process. The factors, based on evidence-based criteria, if present during a patient admission, could contribute to the development of a VTE. The resulting score categorized the patient as low-, at-, or high-risk. Once a risk is determined, the standard bundle of ambulation and/or use of SCDs, if not contraindicated, was provided. Improvement assessed at adherence to VTE screen and bundle elements from 0% to 85%.
Methodology and analysis: The framework used to establish this program was based on the plan, do, study, act (PDSA) cycle. A set of four PDSA cycles to date were utilized to identify the best methods by which this process could be successfully put forth. In the first PDSA cycle, a single department was identified and provided a paper VTE screening tool for staff to identify eligible candidates for bundle utilization. In the second PDSA cycle, the screen was converted into an electronic tool within the EMR and training was developed and provided to the entire institution on usage. At this time, an electronic database was used to aggregate data on compliance of screen and bundle usage. In the third PDSA, gaps in consistent screening and bundle compliance were identified by creation of a VTE champion program with cooperation of a cardiac specialty group. A pre-intervention and post-intervention process based on feedback was added. Champions provided feedback to staff in email and discussion regarding the VTE initiatives. At this time, data was provided to this singular group in graphical format to emphasize the improvement process. Lastly, in PDSA four, the cardiac VTE champions expanded their program to all areas of the hospital with education and videos, utilizing the pre- and post-intervention method. Also, electronic triggers were created with the EHR specialist to aid staff in evaluating patients consistently in order to provide appropriate bundles.
Results: With the interventions put in place during PDSA three, there was an increase in compliance with VTE screen and bundle compliance from 50% to 74%.