Implementing Implementing Charting By ExceptionCharting By Exception

A Method for Streamlining Documentation and A Method for Streamlining Documentation and Making EPIC Work for UsMaking EPIC Work for Us

Katherine Reynolds, RNKatherine Reynolds, RN

Bobbi Schramek, MS, RNBobbi Schramek, MS, RN

ObjectivesObjectives• Define Charting by Exception (CBE) and its Define Charting by Exception (CBE) and its

benefitsbenefits• Identify key components of CBEIdentify key components of CBE• List at least 5 phases of CBE implementation List at least 5 phases of CBE implementation

in a major healthcare organizationin a major healthcare organization• Identify 3 challenges to CBE implementation Identify 3 challenges to CBE implementation

and the strategies to address these and the strategies to address these challengeschallenges

• Identify 2 future considerations for CBE Identify 2 future considerations for CBE implementationimplementation

OverviewOverview

• Skepticism versus RegulationSkepticism versus Regulation• Background for the projectBackground for the project• DefinitionsDefinitions• BenefitsBenefits• PlanningPlanning• Process RedesignProcess Redesign• ImplementationImplementation• EvaluationEvaluation• Ongoing ChallengesOngoing Challenges• FutureFuture

Skepticism against Charting by Skepticism against Charting by ExceptionException

• Regulatory concernsRegulatory concerns– JCAHOJCAHO– IDPHIDPH– CMSCMS

• Legal concernsLegal concerns– Malpractice defenseMalpractice defense– Revocation of licenseRevocation of license

Regulatory RequirementsRegulatory Requirements

• Do not tell us how or where to documentDo not tell us how or where to document

• Do expect that our policies and standards Do expect that our policies and standards are supported by the documentationare supported by the documentation

• Do expect that the policies and standards Do expect that the policies and standards of the organization meet the regulatory of the organization meet the regulatory requirementsrequirements

Legal ConcernsLegal Concerns

• Question of legality is same as regulatory Question of legality is same as regulatory concernconcern

• Must show that policies, standards and decisions Must show that policies, standards and decisions are supported by the documentationare supported by the documentation

• Those policies and standards meet the legal and Those policies and standards meet the legal and regulatory requirements.regulatory requirements.

Age Old Cultural BeliefAge Old Cultural Belief

The old adage, “If it wasn’t charted it wasn’t The old adage, “If it wasn’t charted it wasn’t done…” is clarified in CBE as “If done…” is clarified in CBE as “If interventions, expected outcomes, and interventions, expected outcomes, and patient responses weren’t charted using patient responses weren’t charted using symbols to reflect predefined norms-and symbols to reflect predefined norms-and variances weren’t charted in detail--then, it variances weren’t charted in detail--then, it wasn’t done.”wasn’t done.”

Background of CBE Project Background of CBE Project for ENHfor ENH

• Epic implementation Epic implementation

• Practices of the paper world did not Practices of the paper world did not translate to the electronic world translate to the electronic world

• Point of Care documentation mandatePoint of Care documentation mandate

• Super User Council concernsSuper User Council concerns

EvaluationEvaluation

• Literature Search on Charting by ExceptionLiterature Search on Charting by Exception– Definition of CBEDefinition of CBE– Benefits of CBEBenefits of CBE

CBE—What is it?CBE—What is it?

• Charting by exception (CBE) is a shorthand Charting by exception (CBE) is a shorthand method of documenting normal findings, based method of documenting normal findings, based on clearly defined normals, standards of practice, on clearly defined normals, standards of practice, and predetermined criteria for assessments and and predetermined criteria for assessments and interventions. Significant findings or exceptions interventions. Significant findings or exceptions to the predefined norms are documented in to the predefined norms are documented in detail.detail.

• Murphy and Burke, 1990Murphy and Burke, 1990

Benefits of CBEBenefits of CBE

• Standards allow for consistent quality of Standards allow for consistent quality of care and documentation within care and documentation within organizationorganization

• Abnormal findings are highlightedAbnormal findings are highlighted

• Repetitive documentation of routine care is Repetitive documentation of routine care is eliminated through use of standardseliminated through use of standards

documentation timedocumentation time

Evaluation and Evaluation and RecommendationsRecommendations

• Analysis of current practiceAnalysis of current practice

• Task Force FormationTask Force Formation

Phases of CBE Phases of CBE ImplementationImplementation

• Task Force Formation and EducationTask Force Formation and Education

• Analysis and Process redesignAnalysis and Process redesign

• Foundation WorkFoundation Work– DefinitionsDefinitions– PoliciesPolicies– Regulatory complianceRegulatory compliance– Education PlanEducation Plan

Phases of CBE Phases of CBE ImplementationImplementation

• Development of Epic content and buildDevelopment of Epic content and build– FlowsheetsFlowsheets– Care PlansCare Plans

• ImplementationImplementation

• PI Plan for ongoing evaluation and PI Plan for ongoing evaluation and performance managementperformance management

Task Force Formation and Task Force Formation and EducationEducation

• Multidisciplinary representation on the task Multidisciplinary representation on the task force force

• Education of task forceEducation of task force– CBE definition and key componentsCBE definition and key components– Support materials for successful Support materials for successful

implementationimplementation

• Charge of the task forceCharge of the task force

Analysis and Process RedesignAnalysis and Process Redesign

• Key components of CBEKey components of CBE

• ENH analysis for key componentsENH analysis for key components

• Determination of what was neededDetermination of what was needed

• Change the culture of “If you didn’t chart it, Change the culture of “If you didn’t chart it, it wasn’t done”it wasn’t done”

• Change documentation processChange documentation process

Detailed Detailed ChartingCharting

Charting by Charting by ExceptionException

Normal Normal

FindingsFindings Abnormal Abnormal FindingsFindings InterventionInterventions Completeds Completed Intervention Intervention VariancesVariances

Key Components of CBEKey Components of CBE

• Standards and nomenclature Standards and nomenclature

• Purpose specific documentation toolsPurpose specific documentation tools

• Point-of-care accessibility of Point-of-care accessibility of documentation toolsdocumentation tools

• PI plan for ongoing evaluation of staff PI plan for ongoing evaluation of staff compliancecompliance

Foundation WorkFoundation Work

• Define Charting by Exception for ENHDefine Charting by Exception for ENH• Develop documentation policies to support Develop documentation policies to support

CBECBE• Review for regulatory complianceReview for regulatory compliance• Education PlanEducation Plan

– ContentContent– TimelineTimeline– PersonnelPersonnel

Epic Content and BuildEpic Content and Build

• WNL definitions WNL definitions

• Custom list and definition comparisonCustom list and definition comparison

• Assessment WNL rowAssessment WNL row

• Restructure of flowsheet templatesRestructure of flowsheet templates

Implementation of CBEImplementation of CBE

• Communication with all stakeholdersCommunication with all stakeholders– Superuser Advisory CouncilSuperuser Advisory Council– Clinical Operations CouncilClinical Operations Council– EPICcare MeetingEPICcare Meeting– Staff Nurse Advisory BoardStaff Nurse Advisory Board

• Staff educationStaff education

• Go-live of WNL flowsheetsGo-live of WNL flowsheets

Performance Improvement Performance Improvement PlanPlan

• Audit toolAudit tool

• Compliance audit scheduleCompliance audit schedule

Performance Improvement DataPerformance Improvement Data

• Staff re-educationStaff re-education

Percentage of Assessments using WNL Correctly Comparison by Facility

EV

GB

HP ENH

0%

10%

20%

30%

40%

50%

January, 2005

84 / 199

7 / 30

30 / 70121 / 299

Percentage of Assessments using WNL Correctly

Comparison by Facility

Performance Improvement DataPerformance Improvement Data

• Staff re-educationStaff re-education

• Validation of policies related to WNLValidation of policies related to WNL

• Validation of buildValidation of build

Challenges to CBE Challenges to CBE ImplementationImplementation

• RN understanding of CBERN understanding of CBE

• Culture changesCulture changes

• Row sharingRow sharing

Future ConsiderationsFuture Considerations

• Culture changeCulture change

• Expanding scope of CBE without losing Expanding scope of CBE without losing larger picturelarger picture

Contact InformationContact Information

Katherine Reynolds, RNKatherine Reynolds, RNkreynolds@enh.orgkreynolds@enh.org

847-570-2999847-570-2999

Bobbi Schramek, MS, RNBobbi Schramek, MS, RNbschramek@enh.orgbschramek@enh.org

847-570-2459847-570-2459