Sano and Alexander (2019) highlight the necessity for healthcare teams to seamlessly transition from electronic health records (EHR) to paper workflows to ensure effective care and patient safety. Compliance with national downtime drilling standards, as mandated by The Joint Commission (TJC), and adherence to the doctor of nursing practice (DNP) project site's policies, which require quarterly downtime drills, underline the importance of this quality improvement project.

This project aimed to optimize nursing performance during EHR downtime at a local Midwest clinic. A needs assessment revealed that only 18% of departments completed downtime drills in Q3 of 2023, with 35% having at least one documented drill, and the family medicine department had not completed any drills for the year. The project's objectives were to develop and implement a downtime drilling protocol for the family medicine department using the CLEAR (check, locate, establish, activate, recover) checklist as a framework and to evaluate the intervention's impact on the nursing team's readiness, efficiency, and satisfaction.

The methodology included a needs assessment, scoping literature review, and theoretical framework analysis to design the intervention. This intervention had three components: baseline knowledge survey and education session, mock downtime drill, and post-knowledge check and satisfaction survey. Using the plan, do, study, act (PDSA) cycle, the project incorporated iterative adjustments based on participant feedback and collected data.

The results showed that the family medicine nursing team correctly utilized the CLEAR checklist 98% of the time, demonstrating high competency. Post-workshop knowledge check scores improved by 13.3%, indicating a better understanding of downtime procedures, and satisfaction scores increased by 16.6%, reflecting a positive perception of the workshop's value. The discussion emphasized the intervention's strengths and limitations, suggesting that using the CLEAR checklist enhances preparedness and response capabilities, as well as confidence and satisfaction among nursing staff. However, it also identified barriers such as communication challenges, resource availability, and scenario variability that need addressing.

The project concluded that the CLEAR checklist effectively guided downtime drilling, improving preparedness and response. Future research should evaluate the intervention's impact on patient safety and care quality and explore scalability across different settings and departments.

Lessons learned: Effective training tool: The CLEAR checklist was effective, helping nurses navigate downtime drills with clarity and precision. Team-based approach: Team-based drills revealed real-time operational barriers, highlighting the importance of routine, scenario-based drills. Knowledge retention: Hands-on downtime drill experience aided knowledge retention, evidenced by slight improvements in pre- and post-knowledge check scores.

Strengths: Enhanced preparedness: The project enhanced preparedness by showing nurses how to complete team-based downtime drills using an evidence-based tool customized to departmental needs. Identification of barriers: Drills with various scenarios helped identify and address barriers, optimizing workflow efficiency during actual EHR downtimes. High utilization rate: The high rate (98%) of correct checklist utilization demonstrated its ease of use and reliability.

Limitations: Survey design: The satisfaction survey design might have inflated average scores due to a potential response bias. Only two out of six participants from one team completed the satisfaction survey. Limited satisfaction data: The limited data on satisfaction scores from one team affected the overall assessment of participant satisfaction.

Next steps: Extend initiative: Expand the downtime preparedness initiative to other departments within the clinic and eventually the entire healthcare organization. Customize the CLEAR checklist to each department's needs and conduct similar baseline assessments, workshops, and evaluations. Enhance drill realism: Improve downtime drills' realism and effectiveness by incorporating advanced simulation techniques like role-playing and real-time problem-solving to closely mimic actual downtime scenarios. Develop training modules: Create comprehensive training modules based on feedback and identified knowledge gaps, including detailed videos and interactive modules. Ensure all staff, including new hires, receive thorough downtime procedure training. The project successfully optimized nursing performance during EHR downtime by implementing a structured, team-based drilling protocol using the CLEAR checklist. The high checklist utilization rate and positive satisfaction scores indicate the protocol's value and potential for broader adoption, enhancing organizational resilience and preparedness for unforeseen disruptions.

Christie Martin PhD, MPH, RN-BC, LHIT-HP

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