Critical Thinking Is CriticalVictoria Richardson, RN-BC, Juran Six Sigma Green Belt, Clinical Informatics Manager • Karen Jones, MJ, RN, BSN, CPC, Juran Six Sigma Green Belt, Director of Project Management/Clinical InformaticsSt. Mary’s Hospital • Memorial Regional Medical Center • Richmond Community Hospital

Empower

Enable

Encourage

• People

• Processes

• Technology

• Together canpositively impactpatient outcomes

CRitiCal tHinking nuRSing DefinitionIn nursing, critical thinking for clinical decision making is the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care.1

Critical Thinking is Critical as the transition from paper to the electronic medical record (EMR) progresses.Many of the problems found in paper records are also

found in the EMR which requires staff to continue utilizing their thinking skills and abilities for sound clinical judgments and safe decision making.2

eMR DefinitionThe FDA defines an electronic health record “as any combination of text, graphics data, audio, pictorial or other information represented in digital form that is created, modified, maintain, archived, retrieved or distributed by a computer system.”3

WHy iMpleMent an eMR:Enhance positive patient outcomes including medical

error preventionRemove non-value added activities Improve communication Add valuable timely data reporting and resultsSupport the integration of carePromote Clinical Transformation efforts

tHe obviouSNational Coordinator for health IT EMR Implementation “Requires a delicate balance between the urgency to modernize and the pace of change that can be absorbed by providers and health IT vendors.”

WHat Have tHey Done to uS?Customization • Preference out of complianceWeekly change control Multiple system changesOptimization before stabilizationCommunication without educationNo end user testing or usability

Providers allowed to customize preferences which led to lack of compliance with regulatory requirements, such as Core Measures metrics. Lack of end user testing leads to rework as those who do the job know best how to do the job.

HealtH it anD patient SafetyIt is widely believed that health IT, when

designed, implemented and used appropriately, can be a positive enabler to transform the way care is delivered.Designed and applied inappropriately, health IT

can add an additional layer of complexity to the already complex delivery of health care which can lead to unintended adverse consequences.

Wisdom HierarchyContext Independence

UnderstandingData

Information

Knowledge

Wisdom

Understanding Relations

Understanding Patterns

Understanding Principles

1 Penny Heaslip, 1993, Revised 2008 Thompson Rivers University, Box 3010, 900 McGill Road, Kamloops, BC Canada, V2C 5N3 pheaslip@tru.ca2 Richman, Esq., Fager, and Amsler. "Legal Pitfalls of Electronic Medical Records." Dateline. 12.1 n. Web. 29 Jun. 2013. www.mlmic.com2 Paul, R.W. (1990). Critical Thinking: What Every Person Needs to Survive in a Rapidly Changing World. Rohnert Park, California: Center for Critical Thinking and Moral Critique2 Norris, S. P. & Ennis, R.H. (1989). Evaluating critical thinking. Pacific Grove, CA: Midwest Publications, Critical Thinking Press3 (21 CFR 11.3 (b)(6))

WHat Have We Done to uS?Remind nursing staff to perform initial assessmentAlert which extremity should not be used for IV Display chronic conditions in header with

prompts for treatment“The computer didn’t tell me to call a Rapid Response”Computer alerted to excessive dosing w/o action Actual Best Practice alerts/advisory requests • The clinical decision support tool worked as

designed and did recommend RRT • Is that to take place of critical thinking?

EvaluationAssessment

Nursing Diagnosis

PlanningImplementation

Nursing Process& Critical Thinking

... there is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things.

— niccolo Machiavelli, the prince

As a physician, I am authorized to prescribe thousands of pharmaceuticals and to authorize or perform thousands of procedures. There are countless adverse reactions to be mindful of to prevent the loss of a patient.  No multi-million dollar piece of equipment has saved as many lives as the checklist I tape to the outside of my OR window reminding me to wash my hands and introduce myself to my team before the procedure.  Not a week has passed that it hasn’t saved somebody’s life.  As health care providers we must face our own fallibility.

— atul gawande, World Health organization Director for Reducing Surgical Deaths, associate professor of public Health at Harvard, and author of the Checklist ManifestoMay 9th, 2011 “back to basics”, uW-Madison

DecreasedConfidence

DecreasedCompetence

DecreasedCritical

Thinking

IncreasedSystem

Reliance

Unintended Consequences

Nursing — Critical Thinking = Unintended Consequences

balance