governance, design and optimization of nursing

Connect Care Governance, Design and Optimization of Nursing Documentation Standards in an EHRNursing Improving Patient Outcomes

ScopeThe impact of the AHS Provincial EHR will be felt everywhere that AHS operates, serves and collaborates.

Nursing Improving Patient Outcomes

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Timelines Five year Implementation Fall 2019 – Fall 2023


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Clinical Content

Order / Results Components

Advanced Decision Supports

Clinical Documentation

Clinical Inquiry and Evaluation

Patients, Physicians, Nurses, Allied Health

Organizational considerations – provincial programs, quality and safety, strategic initiatives

Enables providers to make the right decision at the right time at point of care


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Health System Management

Outcomes Management

Documentation Management

Orders and Results Management

Medication Management

Encounter Management

Person Manage

ment

What is & Where is Clinical Content?

• Allergies / Problem List• PIEM – SOGI

standards• Lab workflows, results

management • MedRec, eMAR• Orders, Protocols• Assessments /

Progress Notes, etc.• Standardized data sets

for outcomes measurement

• Standardized content across the health system


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Goals for Documentation • Reduce the burden; eliminate duplication• Evidence Informed Best Practice • Adheres to professional and regulatory requirements • Incorporates decision supports – what an opportunity!!!! • Standardized documentation vocabulary across all care settings /

continuum • Standardized “Scales, Scores and Tools” across all providers / care

settings / continuum• Standardized “Core” set of standards (used by all) and layer on

“Specialty” standards • Supports Collaborative Care and Patient and Family Centered Care


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1. Create the Foundation

Outline and establish clinical governance

Set up projects controls –decision tracking, meeting norms

Establish robust communication processes

Develop outcomes measurement strategy

2. Standardize Processes

Develop principles

Make “Core” (enterprise) decisions

Build off “Core” for specialty decisions

Incorporate eSafety, Human Factors and Intellectual Property Permissions Process

3. Scale Up

Implement

Learn by Doing

Bring different teams together

Consult, Engage and Listen

Solicit information on impact

4. Mature the Approach

Align to strategic directionSupport innovationEnhance decision supports

Support inquiry and self reflection of practice

Refine outcomes measurement strategy

Approach to Standardization – 4 Steps


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• Establish Clinical Governance– For Clinicians by Clinicians – For Patients by Clinicians

• Revisit TOR and membership frequently – Provincial nursing informatics committee was NEW – Over time there is an increase in informatics skill which expands committee scope – With growth and maturity comes changes to responsibilities; take on more

• Document decisions! • Develop outcomes measurement strategy• Make it fun with a committee brand that

everyone is excited about

1. Create the Foundation


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Core Content – Committees Connect Care Content & Standards Committee

Clinical Documentation Committee

Clinical Decision Support Committee

Clinical Improvement Support Committee

Components Committee

Nursing Content Standards Practice Workgroup

Allied Health Content Standards Practice Workgroup

Physician Content Standards Practice Workgroup

Registries Workgroup

Predicative Analytics Workgroup

Clinical Builder Committee

Information Stewardship Committee


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Specialty Content – Area Councils Addictions and Mental

Health Anesthesiology Cancer Capital Management Cardiovascular Services

Continuing Care & Seniors Critical Care Dental Health Child Health Diagnostic Imaging

Lab / Microbiology / Pathology Medicine Neurosciences Financing and Case

Costing

Emergency Medicine (including EMS)

Ambulatory

Primary Care Population & Public Health

Pharmacy Ophthalmology

Transplant & Donor Care Rehabilitation Surgery Renal

Womens Health Others as required


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• Nursing Content Practice Standard Workgroup (NCSPWG)

• First meeting April 17, 2018 • Approximately 50 nurses across multiple specialties and

professions (RN, RPN, LPN) • Set meeting time – every Tuesday am for two hours • Many partners – eSafety, Human Factors, IT,

Professional Associations, Professional Practice, Clinical Content

• Strong Nursing Leadership

NCSPWG


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Role of NCSPWG• Clinical Content – Set the standards and take action to implement• Design – Development and optimization of core/specialty content with system

workflow• Advocacy – Acting as change and communication agents for teams,

programs and sites• Issue Management – Identifying and addressing professional and practice

issues• Risk Management – Identifying risks, impacts and mitigations for a clinical

area• Prioritization – Prioritizing the ongoing CIS requests that is in their realm• Systems Benefits Realization – Measures to track successful

implementation and usage; meeting minimum norm requirements (is the system being used in the way it is intended)

• Practice Standardization (New) – Set the practice standards as a result of technology implementation and take action to implement


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• Develop guiding principles • Make “Core” (enterprise) decisions and stick to

them• Build off “Core” for “Specialty” documentation • Incorporate Human Factors into EHR workflow• Incorporate eSafety & Reporting Learning

System (RLS)• Respect intellectual property - AHS Scale,

Scores and Tools (SST) program

2. Standardize Processes


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Guiding Principles 1. Put patients and families first.

Enhance safety and improve the healthcare experience.

2. Move fast. Make timely, clear and actionable decisions, staying on schedule.

3. Integrate across the care continuum. Favor seamless information flows over niche solutions.

4. Avoid unhelpful variation. Adopt evidence-informed, provincially standardized, guidance and workflows.

5. Adopt and adapt. Express AHS best practice, leveraging vendor content to fill gaps.

6. Use tools for transformation. Do not entrench old inefficiencies in new technologies.

7. Lead with purpose. Maximize engagement of clinical and operational leaders.

8. Partner to advantage. Fully leverage the vendors experience, offerings and relationships.

9. Transform with intent. Monitor and measure expected benefits and unexpected harms.

10. Heed best experience. Collaborate to make the most of your organizations learning and the vendors learnings.


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• Align to project timelines• Implement and move fast; no time to waste• Consult, engage and listen• Solicit information on impact• Success is inclusion and ensure that subject

matter experts come together to collaborate and cooperate

3. Scale Up


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• Learn by doing, be humble and improve• Align to strategic direction – Quality & Safety, Choosing Wisely, etc.• Support innovation – nursing knowledge and procedure integration

into EHR (Lippincott) • Enhance decision supports for nursing – opportunity+++• Support inquiry and self reflection of practice • Empower nurses with their own data about their practice and find

opportunities to improve• Refine outcomes measurement strategy

– Evaluating nursing adoption and how they perceive the system works for them– Nursing care and the impact on improving patient outcomes

4. Mature the Approach (Continuous Improvement)


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Admission• Admission Screenings

– Falls Risk – Schmid (Inpatient); FROP-Com (Ambulatory/Home Care); Scott (LTC); Kinder-1 (ED); Fese (Peds)

– ADL and Assistive Devices – Nutrition – Pressure Ulcers – Braden (Adult); Adapted Glamorgan (Peds) – Suicide (Columbia) – Tobacco– Alcohol– Substance – Domestic Violence – ARO Screening – Values and Beliefs

• Discharge Screening – Living arrangements; Complex needs, etc.

• Covid-19 Identification and Symptom Monitoring


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Physical Assessment• Systems Assessment

– Neurological– HEENT– Respiratory– Cardiac– Peripheral Vascular– Integumentary – Musculoskeletal – Gastrointestinal – Genitourinary – Psychosocial

• Within Defined Limits (WDL)• Standard Definition of Defined Limit

– Evidence Informed Best Practice Approach


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Physical Assessment Example • Neurological WDL

– Alert and orientated to person, place, time and situation – Purposeful motor function – Opens eyes spontaneously – Can communicate needs – Follows commands

• If all of these are met and no other exceptions = WDL

– Reduce the Burden of Documentation

• If there is an Exception – document exceptions– Facial Symmetry – Left Facial Drooping


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Managing Care • In/Outs and Vitals Signs

– Early Warning Systems / Pediatric Early Warning System (Predictive Model) – Sepsis in ED (Predictive Model)

• Daily Cares – Decision Supports Incorporated – Precautions / Falls Interventions / Safe Environment / Comfort Interventions – Mobility / Hygiene / Nutrition / Communication / Entertainment

• Evidence Informed Care Plans – General (Adult, Peds & Neo) – Functional Independence – Pressure Injury – Restraints – Falls – Delirium – Suicide / Depression / Elopement

• Standardized Nursing Handover – IDRAW


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Patient Teaching and Discharge • Safe Discharge Checklist

– 3 days prior to discharge– 1 day prior to discharge – Day of discharge – At discharge – Covid-19 discharge

• Patient Teaching – Standardized: General Education / First Dose Medication / Wound Healing / Falls

Prevention / VTE prevention – Embedded decision supports by linking My Health Alberta Patient Education Handouts – Patient Education Handouts can be printed / sent to patient portal

• Patient Supports – After Visit Summaries provided to patients / available on patient portal – Nurse has a role to include comments on care


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Nurses and the CIS in improving Patient Outcomes

• Patients are taking the initiative to use health technology to be more involved in their care

• The CIS houses the patient story which is available across care settings for everyone on the health care team to see

• Nurses are documenting in the EHR care goals, preferences and what really matters to patients in living with and managing their health issues

• Nurses provide standardized patient teaching and discharge materials in a standardized way and assists patients to better manage their own care


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Successes• Incorporated Evidence Informed Best Practice into documentation • Reduced Burden; if anything we have organized the burden • Avoided duplication and aligned data collection with workflow • Less narrative and more data driven – supports outcomes

measurement • Moved clinicians to accept standardized measures & incorporated

acceptable variance where needed• Reinforced patient safety – standardized clinical information at the

point of care to make decisions (falls, pressure ulcers, etc.) • Created standardized data sets to support self reflection of practice

and provides management with information for health system planning and evaluation of patient outcomes


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Upon Reflection• Rome Was Not Built in a Day! Will Be Built in about Seven Years!• Build outcomes measurement strategy early on

– Nurses satisfaction with CIS; adoption and uptake – Use the documentation data to evaluate impact of nursing care on patient outcomes

• Opportunity to use terminologies for national alignment• Optimize nurses using functionality so get data to evaluate their

care • Emphasis on what matters most to patient care

– Getting back to the premises behind the C-HOBIC Framework – Opportunity to use reporting as a way for nurses to get clinical decision support (spider

graphs)

• Hypothesis and research opportunity: Turning on the System and having nurses use standardized documentation will result in improved patient outcomes (research opportunity)


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governance, design and optimization of nursing

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