Clinical Practice Guidelines/ Knowledge Based … Practice Guidelines/ Knowledge Based Charting ... Clinical Practice Guidelines KBC Overview and Demo to Nursing ... Allscripts expression

08/16/11

1

O

Nursing Practice Councils

Ancillary departments

February 16, 2012

Clinical Practice Guidelines/ Knowledge Based Charting

Overview and Demo

NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf

1

2

Purpose of Meeting

Introduce the QUEST Phase 4 Clinical Documentation project Solicit interested nursing and ancillary dept staff to participate in design sessions Determine acceptance for the use of Clinical Practice Guidelines (CPGs) using Knowledge Based Charting (KBC)


2

3

Agenda

Introduction by Karen Grimley, CNO

Overview/Timeline of Phase 4

Request for design advisors

Project guiding principles and assumptions

KBC/CPG definitions and overview

Demo

Discussion

Vote

Next Steps


3

4

Phase 4

Clinical Documentation

Device Integration

Bar-Code Medication Administration (KBMA)

Patient Classification System (Acuity)

Supporting Strategies: Point of Care (Bedside) Devices, Voice Recognition, TDS Retirement


4

5

Phase 4 Timeline


5

6

Design Advisors Wanted

Represent your council, unit/division/department

Be a permanent member of the Design Team

Attend weekly meetings ( Tuesday mornings, 4 hours) through the end of the year

Solicit input and communicate back to staff

Participate in testing

Participate in training

Serve as Super Users/Red Coats at implementation

Interested? Email meobrien by Feb. 24


6

7

Project Guiding Principles

UC Irvine Medical Center’s clinical systems development shall support our mission to provide quality care and the objectives of the School of Medicine.

We shall incorporate best practices and evidence based clinical content into a standardized configuration for use throughout the Medical Center.

Decision making and design shall be the result of direct participation by frontline care delivery providers whose work is supported by automation.

Our decisions shall be based on doing what is best for the Medical Center as a whole -not a single individual area.

Our care delivery shall be relationship based, collaborative, interdisciplinary, and rooted in clear scopes of professional

practice.


7

8

Project Assumptions

System supplied content will meet 80% of our build need

Voice Recognition may or may not be available by go-live

Selected documents will not be included in initial implementations:

- Intra-procedure/sedation records

- Code Blue documents

- Consents

- Patient questionnaires


8

9

Why we are here

Determine acceptance for the use of Clinical Practice Guidelines (CPGs) using Knowledge Based Charting (KBC)


9

10

Clinical Practice Guidelines

Developed by the Clinical Practice Model Resource Center since 1983 (now part of Elsevier)

Evidence based including Consortium member validation

Over 200 medical, surgical, maternal-child and human response diagnoses

Gives clinicians practical direction regarding assessments, diagnosis and treatment across nursing and allied health disciplines in acute care settings.


10

11

CPG PDF Format (with Grading of Interventions)

11


11

12

Clinical Practice Guidelines: CPG’s

•Guidelines are not prescriptive and do not provide a rigid pathway for diagnosis and treatment.

•They represent an aggregation of the best information on the specific topic, including signs/symptoms, complications, interventions, goals and outcomes.

•The Elsevier CPM approach provides the caregiver with the flexibility to make informed, independent decisions based on the best available information.

•Specific treatment plan remains the purview of the provider.

12


12

13

Problem Identification

Establish Goals/Outcomes

and Provide Education

Assess and Evaluation

Interventions/ Treatment


13

14

Dietitian

Nursing

Respiratory

Care

Reflect Professional

Scope of Practice


14

15

CPG Benefits

Safe, consistent and streamlined care based on the latest evidence

Individualized, patient-centered care at the point of care

Standardization of clinical documentation

Streamlined regulatory compliance

Fosters interdisciplinary collaboration


15

16

Knowledge Based Charting (KBC) is the Allscripts expression of the CPG content into Sunrise and incorporating Sunrise functionality

Additional Content released by Allscripts

Knowledge Based Charting


16

17

KBC Delivery: Layout

17

Patient Populations

Adult

OB

Pediatrics

Newborn

NICU

Main Flowsheets

Plan of Care (POC)

Assessment/Intervention


17

18

CPG and KBC

A CPG is composed of •Goals/Outcomes •Assessments •Interventions •Education

When a CPG is added to a patient, observations become active across the flowsheets The flowsheet is the patient centered interdisciplinary documentation record

18


18

Plan of Care/CPG Integration in Documentation

Guideline

Assessment

Assessment

Intervention

Flow sheet

Education/Outcome

Record

Plan of Care

CPGs


19

20

Documentation Framework

Planning Care

Patient

Education

Evaluation

Toward Goals

Evidence

Based

Content

Learning the

Patient’s Story

Providing Care

Report: Exchange between Professionals


20

21

Demo

•What the Flowsheet looks like

•How CPG content fills the flowsheet

•How the content informs nurses and ancillary providers on the best care to provide

•How to document on the flowsheet

•How to view what was documented

21


21

Clinical Practice Guidelines/ Knowledge Based … Practice Guidelines/ Knowledge Based Charting ... Clinical Practice Guidelines KBC Overview and Demo to Nursing ... Allscripts expression

Documents