Trouble with the Admission Assessment: A Rapid Nurse Efficiency Workflow Project using Plan Do Study Act (PDSA)

Admission documentation had become frustratingly cumbersome and time-consuming. Since implementation there had been changes to the admission navigator without much nursing input on how those changes would affect nursing workflow. This project applied the plan PDSA method.

When changes were added to the EMR little thought was given on how to quantify the documentation burden. One specific example is charting of purposeful rounding. The nurse clicked on 5 rows once per hour, which amounted to 60 clicks per patient for a 12-hour shift. If calculated out for an entire year, this amounted to 15,600 clicks (5 patients/3 shifts per week). If it takes a nurse 24 seconds to complete this documentation per patient, eliminating just this one task saved 24 minutes of time documenting in the EMR per shift. Another example is the admission navigator. The admission navigator was poorly organized causing unnecessary scrolling to find what was being looked for. Nurses described their experience with the admission assessment as confusing, redundant, and time-consuming. One nurse commented, “Can we just add the necessary items and take out the fluff?” Others commented that there were too many items to document and stated they were “unsure of what is really needed or required.” A common theme nurses shared when asked how they felt about the admission navigator was frustration with duplicate documentation, not knowing what was required and to eliminate what was not necessary.

Through the nurse efficiency project (NEP) we revalidated the admission workflow. We reorganized the admission topics and eliminated scrolling making every topic visible at once. We reduced section topics from 40 to 28 (-30%), reduced flowsheet groups from 18 to 6 (-67%), reduced rows from 83 to 38 (-54%), and reduced list selections from 531 to 286 (-45%). We decreased cognitive burden by eliminating interruptive BPAs and queued up care plans, education points, consults, and orders for the nurse to act on all at once. Training and dissemination of the changes were communicated out by a bulletin before each optimization wave.

We got rid of the stupid stuff and addressed a few sacred cows along the way. Nurses decided upon the organization of topics. Admission screenings are now grouped together in one topic and required documentation is indicated next to each assessment. Screenings are meaningful, done when needed, and acted upon as indicated. PHQ-9 was shortened to PHQ-2 and CAGE was reworked in that the nurse does not need to answer all the question if the patient does not consume alcohol. Admission flowsheets had a huge number of items that were unnecessary and now just have what is needed for the admission. We recommitted to charting by exception and eliminated most normal findings from list options. At a recent NEP meeting, nurses shared their thoughts about the admission assessment stating, “It only took me 10-15 minutes to get through an admission,” “It’s great how orders are queued up for me at the end of the admission assessment,” “It makes sense, I know what is required now!”

Learning Outcome: After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.