Preserving Patient Safety after the Implementation of an ......implementation. The electronic system places a patient in the holding area, in the electronic record, while the patient
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Data Collection ...................................................................................................................................... 4
Introduction In September 2013, as part of the Boise State University Organizational Performance and Workplace
Learning (OPWL) program, Team Healthcare formed with the intent of completing a Needs Assessment
(NA) for Holy Medical Center. Throughout the semester, the team completed a formal needs
assessment.
Client Organization Holy Medical Center started as a small community hospital in 1917 by the Sisters of Mercy —bringing
healthcare to the poor and underserved. Holy Medical Center is a not-for-profit, 152-bed acute care
hospital serving the medical needs of the community. In 2010, the healthcare system HC Regional
Medical Center purchased Holy Medical Center making a part of one of the nation’s largest Catholic
healthcare systems.
The associates of Holy Healthcare and its hospitals and medical facilities refer to its Mission, Vision, and Values to guide them as they make decisions for their organizations (see Appendix A for the organizational goals in their entirety). Mission
We serve together in Holy Health, in the spirit of the Gospel, to heal body, mind and spirit,
to improve the health of our communities
and to steward the resources entrusted to us.
Holy Medical Center
152 Bed
Hospital
2 Emergency Departments
HC Health System
4 Hospitals
Multiple medical clinics in 2 states
Core Values
Respect Social Justice Compassion Care of the Poor and
Underserved Excellence
Vision
Inspired by our Catholic faith tradition, Holy Healthcare will be distinguished by an unrelenting focus
on clinical and service outcomes as we seek to create excellence in the care experience. Holy
Healthcare will become the most trusted health partner for life.
Holy Healthcare
82 Hospitals and numerous medical clinics in 21 states
Step #2 Used a systematic approach in identifying the need
Team Healthcare began the investigation of identifying the performance need by using Harless’s (1987)
13 questions as a way to determine if there was a performance problem. It was the team’s desire, as
suggested by Harless, not to “waste” (p. 7) the hospital’s money investigating things that are not
problems. To begin our investigation, the team set out to answer Harless’s first three questions:
1. Do we have a problem?
2. Do we have a performance problem?
3. How will we know if the problem is solved?
Step #3 Collected data to establish the need
To investigate the existence of a gap in performance, Team Healthcare purposely looked at various
sources of information to triangulate our findings. According to Miles and Huberman (1984)
“Triangulation increases our confidence about a finding by helping us determine if other sources echo it”
(as cited in Rossett, 2009, p. 3).
The team used several data sources, as well as several methodologies by which to collect and triangulate
data to verify that there was a performance gap. Table 3 outlines the data the methodologies and data
sources the team used to assess the gap and verify the need for a complete NA. The impact of the data
is provided following table 3.
Table 3 Data Collection Methods
Data Collection Methods
5 Individual Interviews
Physician Liaison- Clinical Informatics Department
Orderset Coordinator- Clinical Informatics Department
Clinical Liaison- Clinical Informatics Department
Clinical Educator- Clinical Education Department
Charge Nurse- Emergency Room
Audit of 14 files Due to concerns of violating patient confidentiality, Team Healthcare was unable to review charts. Hospital personnel audited the charts.
Step #4 Analyzed data and summarize key findings
Evidence from both patient chart audits and interviews with key personnel, prove there is a gap
between the required and current state of discontinuing the electronic orders.
As outlined in table 3, of the 14 charts audited, the auditors classified approximately 70% as not up to
hospital standards. An interview with the Clinical Educator indicated that one nearly fatal mistake
occurred, due to improper orders management, but fortunately, competent staff diverted a possible
fatality. Furthermore, in an informal interview with Medical Unit and Intensive Care Unit (ICU) nurses,
the team asked nurses to rate, on a scale of 1 to 5 (1 being not well at all and 5 being really well), how
well the orders are cleaned up in a chart when they receive a transfer patient. The nurses answered
with an average of 2.17, which further points to an issue with orders management during transfer. The
client indicated that average of 4 would be expected and 5 would be optimal.
Table 4 Overview of Collected Data
Data Collection
Method
Reviewed by or
Interviewee
Data
Audit 1 Physician Liaison 3 out 4 files from the Emergency Department were not cleaned
up as they should have been
Audit 2 Orderset Coordinator 3 out 5 files were clearly not updated properly before the
transfer
Audit 3 Charge Nurse 4 out of 5 charts are not cleaned up when charge nurse puts in
admit orders
Interview Clinical Liaison Approximately 70% of charts audited are not updated properly
Interview Clinical Educator “The only evidence I have is the comments I hear from the 2
directors of the receiving floor that the orders are not cleaned
up” “We have had 1 incident where there was some confusion
with which orders where current and were not which almost
caused a deadly situation.”
Interviews (informal) 3 Medical Unit nurses
3 ICU nurses
On average, gave the following question a 2.17: On a scale of 1 to 5, 1 being not well at all and 5 being really well, how well do the nurses perform the transfer handoff process?
Step #5 Answered Harless’s first 3 questions
1. Do we have a problem?
Yes, nurses are not properly completing the orders management process in the
Electronic Health Record before transferring a patient to another unit.
2. Do we have a performance problem?
The nurses sometimes complete the orders management process, which indicates this
may not be a knowledge or skills problem, but instead a performance problem.
3. How will we know if the problem is solved?
We will know the problem is solved, when nurses are completing the orders
management process in the Electronic Health Record before transferring a patient from
the ER to an inpatient unit, more frequently than 30 % of the time (the estimated rate of
compliance), eventually reaching 100% compliance.
Step #6 Defined the need
Team Healthcare defined the need as:
The ER must increase the frequency at which the nurses complete the orders
management process in the Electronic Health Record before transferring a patient to an
The team found using the BEM and SAM also helped us “to observe behavior in an orderly fashion and
ask the ‘obvious’ (the ones we so often forget to ask) toward the single end of improving human
competence” (Gilbert, 2007, p. 95).
Step #2 Collected data to establish the causes
As outlined in Table 5, a large portion of the data collected was qualitative data, obtained by one on one
interviews. Following the suggestions of Schensul and LeCompte (1999), the interviewer captured the
responses to the interview questions, verbatim. A third party conducted onsite observations of the
process, using a checklist provided by Team Healthcare. Due to concerns for patient confidentiality, the
team was unable to audit patient files, but did have onsite personnel conduct them and provide the
team with the results. Finally, the team reviewed training agendas provided by the Clinical Informatics
Department, the department responsible for training during the implementation and for ongoing
support for the EHR.
Table 5 Data Collection Methods Data Collection Methods
17 Individual Interviews
Unit Nursing Directors x 2 – Medical Unit and ICU
Physician Liaison- CID
Orderset Coordinator- CID
Clinical Liaison- CID
Clinical Educator- Clinical Education Department
Charge Nurse- ER
Staff Nurses x 2 – ER
Staff Nurses x 3 – Medical Unit
Staff Nurses x 3 - ICU
Clinical Informatics Specialists x 2 - CID
14 File Audits Due to concerns of violating HIPAA regulations, Team Healthcare was unable to review the charts personally. Hospital personnel audited the charts and relayed the information to Team Healthcare.
4 Observations
The team created an observation form, which the client and her colleague used to conduct observations of nurses completing the transfer process.
Review of Support Materials
The team reviewed training agendas used for implementation training to determine if the training covered orders management during transfer.
Step #3 Identified major and minor data trends
After collecting the data, the team used a deductive approach to coding the data (as outlined in table 6).
Using the advice from LeCompte and Schensul (1999), the team coded and organized the data into
categories related to the BEM/SAM framework. The team then color coded the data and then
quantified the data by counting each piece of data to identify trends.
Once the team and the client agreed on suitable interventions to fill the performance gap, the team reviewed the
selected interventions to ensure they were in alignment with Holy Medical Center’s organizational goals. Table 10
outlines at which level (Watkins et.al, 2012) the intervention will impact the organization and how the intervention is in
alignment with the goals of the organization.
Table 10 Interventional Alignment with Organizational Goals
Intervention Level Link to Organizational Goal(s)
Provide clear and accurate information regarding task responsibility
Operational Goals:
Implement processes that are Lean
Provide excellence in the care experience In the past three years, there has been an organizational focus on Lean processes. The organization looks at all processes and asks, “Is the way we are doing this a ‘value add’ (adding value)?” The Lean philosophy challenges the associates in the organization to look at current processes and find ways of doing them more efficiently and effectively. Currently, the ER nurses are not completing the process or only partially completing the orders management process. This puts a burden on the receiving unit nurses – they spend productive time attempting to decipher the orders. Not only is this inefficient, it could compromise patient safety. By clarifying to the ER nurses what their responsibilities are related to the orders management process during transfer, they will more effectively complete the process, thereby, saving time for the receiving nurses. This helps the hospital meet their goal of being a “Lean” organization. The nurses completing the process correctly will mitigate confusion for the receiving nurses. They will no longer have to ‘guess’ which orders are current. An accurate and complete chart represents a safer environment for patients, which helps the hospital meet their goal of providing “excellence in the care experience” (see Appendix A).
Provide clear communication of performance expectations regarding task
Operational Goal:
Earn a 4 on the Joint Commission mock survey
A hospital goal for the year 2014 is to receive a score of 4 on their Joint Commission mock survey. A 4 indicates that the mock surveyors find 10 or fewer violations and/or opportunities for improvement. The Joint Commission requires that the nurses follow a standardized process during a handoff (Friesen, White, & Byers, 2008). By communicating to the nurses the expectations for performance related to the orders management process during transfer, nursing performance should improve both in the orders management process and the overall transfer process. If nurses improve their performance, the hospital will avoid a violation during the mock survey, which will help the hospital achieve their goal of a 4.
Appendix A. Mission, Vision, Values of Holy Healthcare Mission We serve together in Holy Healthcare, in the spirit of the Gospel, to heal body, mind and spirit, to improve the health of our communities and to steward the resources entrusted to us.
Core Values
Respect - We value and esteem every human person because each and every one is created by God, in the image of God. Everyone, regardless of title or position, income, education or status, race, religion or ethnicity has a dignity that is sacred. We treasure and hold human life sacred from its simplest beginnings until its end. (Gen. 1:26; Luke 9:47-48; John 10:10)
Social Justice - In this age of globalization and instant communication, we more quickly recognize our common humanity. We recognize as well the great gaps in economy, health, education and development among the peoples of this earth. Social justice commits us to the common good so that all may have their basic needs met. We recognize health and access to healthcare as a basic human right and seek to provide and advocate for it. (Wisdom 9:2f; Isaiah 32:16-18.)
Compassion - People come to us when they are in need and in distress. In the spirit of Jesus, we recognize their need and seek to respond to it. We reach out to them in their pain and suffering and care for them in body, mind and spirit. The ability to feel and to respond to the suffering of others is an essential value in our ministry of healthcare, no matter where we serve. We recognize also that those we cannot cure we can still love, care for and be with in their suffering. (Mark 1:40f; Mark 10:51; Luke 4:40 Luke 10:30-37; Romans 12:15; I Cor. 13:4-7)
Care of the Poor and Underserved - God hears the cry of the poor and so, with respect and compassion, we seek out the poor and underserved as a special focus of our healthcare ministry. It is those without resources of their own who need us most. We seek to care not only for their immediate needs but also to change the structures that keep them in unhealthy environments and inhumane conditions. Through our ministry of health care and our persistent advocacy, we seek to serve the poor and underserved of our communities. We too hear the cry of the poor and underserved. (Acts 4:32-35; James 2:15)
Excellence - The scriptures look to the day when there will be a new heaven and a new earth, when creation will be made perfect. Our vision is no less. In all we do, we reach for more -greater respect, fuller justice, deeper compassion, better care, less poverty. We are impatient to do better and hold ourselves accountable for continuous improvement in the services we offer. (Matthew 25:14-23; II Corinthians. 9:6; Revelations 21:1)
Vision Inspired by our Catholic faith tradition, Holy Healthcare will be distinguished by an unrelenting focus on clinical and service outcomes as we seek to create excellence in the care experience. Holy Healthcare will become the most trusted health partner for life.
RN Director Interview Guide Date: Interviewer: Interviewee:
Question Response Please describe what Genesis is and what was the main purpose of implementing it at the hospital? Probe if needed: ● How was this message shared with the RNs?
● Do you believe the purpose has been reached?
How has the new online orders management process changed hospital processes? Where have you noticed the biggest impact? Probe if needed:
How has the transfer process been impacted?
How has the handoff process been impacted?
Do you have anyone who has truly been an exemplary performer since the implementation? Why have they embraced this change so well?
What type of support was originally given to the RN staff to learn the system and what support is given today? Probe if needed: ● How was training given? ● How is the information kept up?
● What is your role in this support?
What are some of the barriers that you believe might be stopping the RNs from doing the orders management process in the EHR? Probe if needed:
Do the RNs have the skills to use the system?
Do the RNs have the knowledge to use the system?
Are the nurses motivated to do the orders management process?
What are the consequences for not keeping up the EHR? Who is responsible for making sure these consequences don’t occur? Probe if needed: ● How would a nurse know when he/she isn’t meeting standards?
● Who monitors standards?
When I talk to the nurses, what do you believe they will say if I ask them what they need to be successful in complete the orders management process on a consistent basis?
What else would you like to share about this current situation with the EHR?
RN Director Interview Guide Date: 10/08/2013 Interviewer: Angie Wolthuis Interviewee: Director of ICU
Question Response Please describe what Genesis is and what was the main purpose of implementing it at the hospital? Probe if needed: ● How was this message shared with
the RNs?
● Do you believe the purpose has
been reached?
Purpose –INFO and MVTN it was a top down initiative, but the nurses do not care about the WHY. INFO and MTVTN I don’t know that they fully understand the purpose, however, it does not matter. They know those types of decisions cannot be changed, so they want to quickly incorporate it into their practice so they can continue to do good work.
How has the new online orders management process changed hospital processes? Where have you noticed the biggest impact? Probe if needed:
How has the transfer process been impacted?
How has the handoff process been impacted?
Do you have anyone who has truly been an exemplary performer since the implementation? Why have they embraced this change so well?
The nurses have done a good job adjusting to the new EHR. INFO The whole process is electronic now, which is a huge change. In the past the nurses charted in Meditech, but the orders were not in the chart. Meditech was different as well because we had the ability to make changes based on our needs. We could ask for a change and it would happen in a day (changes to help with workflow, etc.). The new system is a universal system for the entire corporation, so one change is huge because it impacts everyone. ORG We can no longer make changes based on our needs. ORG We can make requests, but there are not guarantees as to if the changes will be made or not. This change of not really having any say in the way the system works is huge. ORG The system used to work for us, now we work for the system. Cerner designed the system for Evidence-Based Practice (EBP). EBP is one size fits all. ORG The system is not bendable; the culture has to bend to fit the system. It has changed INFO the transfer process because it is a disruption in the workflow. There are interruptions by the system (EBP reminders, etc.) – interruptions disrupt the thought process and it takes time to get back on track. Nurses are used to getting focused and completing a task, now they are RSRC constantly interrupted by the system reminding them to do things. There is also SO much information on a chart. It is difficult to sort through all the information.
What type of support was originally given to the RN staff to learn the system and what support is given today?
KNWLDG The training was all done in a “fake” environment. It was all theoretical. We were not able to use a live system and practice on real charts. The real learning happened on the day of the go-live. It is impossible to teach everything in the training – you just cannot prepare people for every situation they will encounter in
the real world. A lot of people are tactile learners and will only learn by actually doing it. Another issue with the training was that ORG the people doing the training were not nurses. They were non-clinicians, so their brains process differently. It would be more effective if it were clinician to clinician training. The ones that were more effective that were not clinicians were educators (there was a gentleman that was a former teacher). He was effective because he understood how to teach. He had a training background. INFO and RSRC The directors disseminate all of the information to the nurses. Job aids come from somewhere… not sure where and we are expected to get them to the nurses. They are difficult to understand and way too long. INFO We don’t know who to contact to implement changes or who to talk to about training. (Angie: I followed up with, what about the Clinical Informatics Department - don’t you have a relationship with them?) I don’t know what the relationship between the hospital and the CID should be. INFO I don’t even know who to contact for training support or questions. I am a director, if I don’t know who to contact, how will the nurses know who to contact. ORG We don’t even know who our support from the CID should be. Shellie does something, but I am not sure what. We have no on sight support. The main location has a number they call and they get at the elbow, we have no at the elbow. We don’t even know who to call to ask for help.
What are some of the barriers that you believe might be stopping the RNs from doing the orders management process in the EHR? Probe if needed:
Do the RNs have the skills to use the system?
Do the RNs have the knowledge to use the system?
Are the nurses motivated to do the orders management process?
There are huge generational differences in the nurses. The younger generation is great with technology, but the older generation is experienced. For the experienced RNs, there has been a huge cultural shift. They were experts and now they are novices. KNWLDG I think some of the RNs do not feel confident in their computer skills; it has made them question their abilities as nurses.
What are the consequences for not keeping up the EHR? Who is responsible for making sure these consequences don’t occur? Probe if needed: ● How would a nurse know when
he/she isn’t meeting standards? ● Who monitors standards?
Patient safety is compromised. There are time delays. RN Consequences – the process implemented is not the RNs fault. We use Just Culture in the organization and we try to find out the root cause and understand why something is not working. MTVN We don’t punish people unless they are intentionally doing something that will harm patients.
When I talk to the nurses, what do you believe they will say if I ask them what they need to be successful in complete the orders management process on a consistent basis?
1:1 help –KNWLDG they need an expert with them. They never had a real expert at their elbow. They had had super users on the floor, but these were not necessarily experts in the process. If every nurse could have 1:1 help for a month – to ask about any situation that may arise (as not all situations arise every day), they could be consistent. They also need tools that are readily available. The job aids are on a website, but everything is there. RSRC If you are in a hurry, you do not have time to sort. I don’t have time to sort through them, I know a nurse does not have time to sort through them. There is too much information there. RSRC They need simple job aids with bullet points – do this, do this, do this. Not 15 page documents with step by step instructions, including the why they are doing it. It needs to be succinct. They need to be able to get to them quickly – one click, not fifteen clicks.
What else would you like to share about this current situation with the EHR?
RSRC The directors are responsible for auditing the charts, which adds even more to an already huge workload. RSRC We don’t know who to contact to implement changes.
When I talk to the nurses, what do you believe they will say if I ask them what they need to be successful in complete the orders management process on a consistent basis?
RSCRC More time – not to feel so much pressure about time.
KNWLDG Better knowledge of the system and the processes.
INFO We need to reiterate the message that it is okay (in reference to the earlier
comment about it being the doctor’s job) to clean up the orders – we need a
clean slate when the patients come to our floor. This helps everyone do their job
Nursing Questions- Nurse #2 (Supervisor) Unit Nurse is on: Emergency Department Any experience with EHR in past? Yes, but not Computerized Physician Order Entry
1. Why did the hospital move to the Electronic Health Record (EHR)?
MTVN This was an initiative from the corporate office. To meet certain standards with the federal government, they had to go electronic. I don’t know if there are better systems out there, but everyone in health care will be in the same boat. I think for some things it is better (you don’t have to look for the patient’s chart), but for other things, it is not that great. INFO We will just have to figure it out.
2. How has the implementation of the EHR impacted the time it takes to transfer a patient (as an admit to the floor)?
It has definitely slowed things down. RSRC It takes more time to do pretty much everything and in the ER, that is rough.
3. When transferring a patient to the floor, whose responsibility is it to clean up the orders (e.g. discontinue, complete, etc.)?
How comfortable are you cleaning up orders?
Has the process been document or explained to you?
It depends; there is some drama around this. INFO The charge nurse is supposed to do the admit orders, so it can be a little unclear about who is supposed to do the other pieces. The nurse, in theory, should discontinue and complete orders, but they don’t always do it. MTVTN I would not say they are all comfortable with discontinuing orders. When we had training – KNWLDG it seems like they just “skipped over” this. I am INFO not sure if it is very clear as to what is okay and what is not okay.
4. If you had trouble with the EHR system, not the computer itself, but questions on the process, do you know who to contact for support?
Would you contact someone for support if you knew who to contact?
We would go to someone in our department – or Shellie (someone local that does not have the primary responsibility for training). INFO I don’t think that anyone knows how to get a hold of the people in the main location. I may call them if I needed help, but I don’t know how to get a hold of them.
5. Do you know how to locate the job aids that were made to help you with the EHR?
Hmm, job aids – I know what you mean, but I have RSRC no idea where they are. I don’t know if they would be helpful because things move so fast, I don’t really have time to refer to something that is that long – their job aids are long.
6. Help me understand how hard or easy it is to find information on the charts? Is it easy or hard to sort through information?
When we get the patient, it is easy as we are the first point of contact. INFO However, finding infor on the charts can be confusing. The other day we had an MD call us from the Health Plaza. He had a little boy that had been in the ER and wanted to know about the X-Ray we did on him.
7. What is your comfort level using the computer?
KNWLDG I am fine using a computer – this is just a totally different system than I am used to.
8. If you don’t clean up the orders before you send the patient to the floor, what happens?
MTVN It depends. Sometimes the floor calls us – other times they just figure it out.
ADDITIONAL QUESTION (This nurse is a supervisor in the ER)
9. What kind of feedback do the nurses get if they do not complete the transfer process correctly?
What is the feedback from the supervisor or leader if they do not complete their orders before the transfer?
INFO If we catch anything as supervisors or charge nurses, we will talk to them. Patient safety is the most important thing to any nurse, so we want to make sure the patients are taken care of and safe. INFO We don’t really have a system in place to check to see if the orders are taken care of before they are transferred. Again, I am not sure if anyone knows whose job it is. It is not the MD’s job to do it in the system – they wouldn’t have time. The nurses should be doing it, but if they aren’t, they may not know it is their responsibility.
Nursing Questions- Nurse #3 Unit Nurse is on: Emergency Department Any experience with EHR in past? Quite a bit of experience, but not Computerized Physician Order Entry
1. Why did the hospital move to the Electronic Health Record (EHR)?
Every hospital and health care organization has to move to an computerized charting system. MTVN It is a part of Obamacare.
2. How has the implementation of the EHR impacted the time it takes to transfer a patient (as an admit to the floor)?
I have quite a bit of experience with electronic charting, so I don’t think it has really changed the time it takes me. RSRCS It may take a little more time, but not much.
3. When transferring a patient to the floor, whose responsibility is it to clean up the orders (e.g. discontinue, complete, etc.)?
How comfortable are you cleaning up orders?
Has the process been document or explained to you?
INFO The nurses are supposed to clean them up, I think, but it probably doesn’t always happen. It gets a little confusing with the holding orders, the admit orders, and the ER orders. It can be confusing as to who is supposed to do what. KNWLDG The process hasn’t really been explained; maybe it has, but I forgot. We had so much to learn, that is just one piece of it. I can’t really remember what they told us. (Future opportunity: Training)
4. If you had trouble with the EHR system, not the computer itself, but questions on the process, do you know who to contact for support?
Would you contact someone for support if you knew who to contact?
INFO Not like a formal help line or anything. I would maybe call someone if there was a number for support.
5. Do you know how to locate the job aids that were made to help you with the EHR?
RSRC I know they showed us where they are, but I don’t remember.
6. Help me understand how hard or easy it is to find information on the charts? Is it easy or hard to sort through information?
KNWLDG Finding information can be tricky, but I have a lot of experience, so I am fine.
What experience do you have in using the EHR? Did you work with any of the nurses or managers to create the training? How was the course piloted before the roll out and to whom?
Who participated in the training? Probe if needed:
Was this mandatory training?
Did the managers have to participate? Do you know if you had 100%
attendance? Do you have records?
What were the course objectives for this training? (goals)
Probe if needed:
Who set the course objectives?
Were there any constraints such as limited of time, space, budgets to providing this training? Describe them.
Describe what training the nurses had on the orders management process during transfer. Probe if needed:
Describe how you showed or demonstrated to your participants how to use EHR.
Were they trained on workflow process
or only functionality?
What type of hands on practice did your audience get during training? Did they get on the computer and actually practice?
How did the nurses know if they were doing the orders management process correctly during training? (What type of feedback did they get?)
Describe to me how your participants were evaluated to determine competency of what they learned?
• During the training did you discuss the why of orders management?
• Do they understand why they need to
Clinical Informatics Department Trainer Interviews
Date: 11/18/2013 Interviewer: Angie Interviewee: Trainer P
Question Response
What experience do you have in using the EHR?
Did you work with any of the nurses or managers to create the training? How was the course piloted before the roll out and to whom?
I was hired to help with the implementation. The training was already created and I believe it was created by the Holy Healthcare, the parent company.
The hospitals have been using the same content for all of the go-lives in the system, so it was not piloted at our site.
Who participated in the training? Probe if needed:
Was this mandatory training?
Did the managers have to participate?
Do you know if you had 100% attendance? Do you have records?
KNWLDG There was training for everyone working in the hospital: Provider training, RN training, ancillary services training, billing training, registration, etc.;(team note: no orders management?) they were all split out by what they did. Training was separate for each “group” of people and all managers were required to participate.
Training was mandatory and people were not allowed to work until they completed the training.
There had to be 100% attendance as anyone that didn’t attend was not allowed to work.
What were the course objectives for this training? (goals)
Probe if needed:
Who set the course objectives?
Were there any constraints such as limited of time, space, budgets to providing this training? Describe them.
There are too many objectives to cover. We really wanted them to be able to use the system and be confident in their abilities to do so. The course objectives were set by the parent company. We had time constraints for sure. We had to get everyone trained by the go-live and had just a couple of months to do it. There are always budget constraints, but the nurses were paid for the training and if they needed additional training, they were paid for that as well. (Team: Note for future opportunities training improvement)
Describe what training the nurses had on the orders management process during transfer. Probe if needed:
Describe how you showed or demonstrated to your participants how to use EHR.
Were they trained on workflow process or only
INFO Orders management is the job of the provider (doctor). The nurses are there to facilitate it (they can take the orders to do it over the phone or verbally), but it is really the responsibility of the provider. If they are going from the Emergency Department to Inpatient the nurses call the physician they are admitting the patient to and let that MD know. The admitting MD goes through the meds. KNWLDG The nurses were trained on both process and functionality. The
What type of hands on practice did your audience get during training? Did they get on the computer and actually practice?
How did the nurses know if they were doing the
orders management process correctly during training? (What type of feedback did they get?)
Describe to me how your participants were evaluated to determine competency of what they learned?
• During the training did you discuss the why of
orders management?
• Do they understand why they need to complete and/or discontinue the orders?
• Was there any hesitation when it came to
orders management on the part of the nurses?
• If so, why were the nurses hesitant?
practice was process, but of course we could not cover every situation in training. The KNWLDG RNs did get hands-on practice. They were all assigned to a workstation and they used them during the class. We had fake patients loaded with real data, provided to us by the parent company and created by real nurses. INFO I wouldn’t say we gave them feedback during training about that – we just really hammered things hard during our presentation. They were given quizzes at the end of each section. If they didn’t pass, they had to have more individualized training with a trainer. KNWLDG Eventually, everyone had to pass in order to go back to work. (team how do we know?)
The why was discussed – keeping the chart clean so that there are no mistakes with possible duplicate orders, etc. MTVTN However, nurses see orders management as “not my problem”. If they are the transferring nurse (particularly from the ED to inpatient), they see that the receiving nurse will be responsible for the care of the patient and will therefore be the scapegoat if there is a mistake. ED nurses say they do not have time to do the orders management process. RSRC The hesitation is time. It takes too much time and they INFO and MTVN feel some of it is out of their scope of practice.
What was the support plan for nurses after training? Probe if needed:
• Are there job aids available on the topic or orders management during transfer?
• How do they access the job aids? • Who do they contact for support? Do they have
access to help from the CID team and how do they know who to contact?
• How often do you get calls from the Other Location nurses?
• What would you say the majority of those calls are about?
• Do nurses have the option to take advanced training? If so, is orders management during transfer part of this training?
What does that advanced training cover and how does it cover that material (hands-on training, scenario-based)?
The nurses were given at the elbow support from super-users for approximately a month. After the support went away, RSCRS they were told to call ext. 5448, which is the CID team (support team). That number is RSRC available M-F 7am to 7pm and there is someone on call on the weekends as well. We do get calls from Other Location nurses. I remote in on their computer and sometimes look to see what the problem might be. This allows me to see their screen and what they are working on. The calls are mostly about charting. There are job aids on a Sharepoint site. RSCS I would say there are at least 100 job aids. There is probably too much info for them there and I have been told that they easily get sidetracked on the site and it is probably hard to find exactly what they need. They will be required to take advanced training in the next couple of months. They will be paid for their time in advanced training. I am not sure that everything is finalized on what the advanced training will cover, but I am sure it will be hands-on.
Clinical Informatics Department Liaison Interviews
1. On a transfer who holds the primary responsibility for orders management during the transfer process?
(The physical
process in the EHR,
not responsible for
determining which
orders continue or
not.)
2. Are the nurses doing it? If not, why do you think the nurses are not doing the orders management during the transfers?
3. Do you have any evidence that tells you they are not doing it?
4. What do you do with the evidence that this the orders management is not being done?
Physician Liaison
Clinical Informatics
Department
1. INFO The nurses, they don’t do it, but it is their job.
2. INFO I think there has just been so much going on and no one is really clear on what their role is. Each hospital is different, so that can be challenging as well. ORG They have their own policies and sometimes our team is not even 100% clear on who is supposed to do what in each hospital.
3. INFO We audit the charts from time to time for our purposes, but in my audits, I have noted that the orders from the Emergency Department were not “cleaned up” as they should have been. I just did an audit last week and 3 out of the 4 charts were not properly updated.
4. Since most of our audits are informal, and more for the purpose of gathering information, I don’t do anything formalized with the information. My primary responsibility is to work with providers (physicians and mid-levels), and if there is something that is directly affecting them, it becomes my problem to solve. INFO At this point, I just noted the information and may bring it up to colleagues if it seems to be an issue.
Orderset Coordinator
Clinical Informatics
Department
1. INFO The nurses should be doing it – the actual in the computer piece. They obviously consult with the MDs on this, but they should be completing or discontinuing orders; cleaning them up.
2. INFO No, they are not consistent about it at all. I think they just aren’t sure about what their responsibilities are when it comes to this process.
3. Our department does chart audits from time to time and since I used to support the Emergency Department in the main location I look at ED stuff. Last week we all did some independent audits (your project has brought some awareness to this topic) and I found that 3 out of the 5 charts were clearly not updated properly before the transfer.
4. While my job is to review orders, it is merely for the purpose of making sure the orders that we built (the organization builds ‘sets’ of orders) are working correctly. I review the ordersets or the PowerPlans and note any issues with those. I noticed this in my audits because you asked us about it. INFO I merely gathered the information for you and we will probably note the information as a department and disseminate it to the directors at all sites.
Clinical Liaison
Clinical Informatics
Department
1. INFO The nurses should be doing the clean-up in the charts, I suppose. Really, I think the doctors should do it, but everyone says that since they won’t do it, so it falls on the nurses. That is typical – the nurses come behind the docs and clean up their messes! In this case, the nurses should be doing the clean-up after they have consulted the providers on what orders should and shouldn’t continue.
2. ORG I don’t think they are doing it in the other location like they should be. It is probably something that was lost in translation during the whole go-live process. We may need to go back and clarify things to them.
3. Yes, I am responsible for looking at clinical issues within the system. While I am not the clinical liaison for that site, I do look at issues in the system as a whole and it was recently brought to my attention, through some audits, that orders are not being properly managed during the transfer process (and in general). This is on my radar now. (Follow-up from interviewer: In the audit process, how many charts would you say are updated correctly during the transfer process?) I would say probably about 25-30% are correct. That is nowhere near where it needs to be. I would like to see 100%.
4. I did the audit at your request. INFO We did note the issue and will bring it up at IOT (a meeting that involves people from the corporate office as well as local leaders – they assign problems for resolution and report on those at this meeting). We have brought it up before, but the other location does not always have a representative at the meeting. They are always invited, but they are also in the middle of building a new “hospital” (heart care unit and maternity unit) and they have been working tirelessly to get this done. I will communicate the issue to them again and discuss it with their clinical liaison.
Clinical Educator
Clinical Education
Department
1. The nurses should do the orders management, but it can be a complex process. There are holding orders, admit orders, and current orders. It can be a little tricky to know who is supposed to do what.
2. From what I observed during the observations, they are “kind of” doing it. They are doing it to a point, which is why I checked “yes” on the observations, but they are not completely doing the entire process. Now that I think about it, I should have probably made more notes on the observations that talked about how they didn’t fully complete the process.
3. The only evidence I have is the comments I have from Directors or the receiving floors telling me that the orders are not cleaned up. We did have one incident where there was some confusion with which orders were current and which were not – it could have been a deadly situation, but it wasn’t. One near miss is enough.
4. It is not necessarily my job to fix this issue, but I do bring it up to the directors. I also was hoping you (Team Healthcare) could bring us some recommendations!
Charge Nurse
Emergency Department
1. I suppose it is the nurse’s job– well I am pretty sure it is, but it doesn’t get done like it should. It just doesn’t.
2. They are not doing it like they should. I think some of them know, but don’t have time and others are just not sure what is their job and what is the job of the MD.
3. When I charge (work as the charge nurse), I put in the admit orders and I see all the charts. From seeing these charts I know that they are not doing it. (Follow-up from interviewer: How many charts, out of every 5, would you estimate, do not have the orders cleaned-up like they should be?) Probably 3 out of every 5 do not have the orders cleaned up. Maybe even 4 out of 5. They are pretty consistently not cleaned up.
4. I do bring this up at huddle, but at this point I think I need the process and the responsibilities clarified myself.
Below is the data the team collected from informal interviews conducted verbally with 6 Holy Medical Center nurses. Question Medical
Floor Nurse
Medical Floor Nurse
Medical Floor Nurse
ICU Nurse
ICU Nurse
ICU Nurse
Average
1.
On a scale of 1 to 5, 5 being really well and 1 being not well at all, how well does the transfer process, including the “computer” piece of it, work?
2 4 3 4 5 5 3.83
2.
On a scale of 1 to 5, 5 being really well and 1 being not well at all, when you receive a transfer patient to your unit, how well are the orders cleaned up in the chart (orders that are no longer relevant have been discontinued)?
3 2 1 3 2 2 2.17
3.
On a scale of 1 to 5, 5 being really well and 1 being not well at all, typically, how well does the verbal handoff process go between nurses (how thorough is it)?
4 3 4 5 4 3 3.83
4.
On a scale of 1 to 5, 5 being always and 1 being never, how often do you open the patient’s chart during the handoff process and review with the transferring nurse (either on the phone or in person)?
5 5 5 2 4 3 4
5.
On a scale of 1 to 5, 5 being I completely agree, and 1 being I do not agree at all, I understand my role in the orders management process (cleaning up orders) during a transfer.
Results of Informal Poll with Nursing Directors and Clinical Educator
Below is the data collected from informal interviews conducted verbally with 2 nursing unit directors and the clinical educator at Holy Medical Center.
Question ICU Nursing Director
Medical Floor
Nursing Director
Clinical Educator
Average
1. On a scale of 1 to 5, 1 being not well at all and 5 being very well, how well does the transfer process work overall?
3 3 2 2.67
2. On a scale of 1 to 5, 1 being not well at all and 5 being really well, how well do the nurses perform the transfer handoff process?
3 3 3 3
3.
On a scale of 1 to 5, 1 being not well at all and 5 being really well, how well are the orders “cleaned up” in the patient chart when you receive a patient on your floor?
3 3 3 3
4. On a scale of 1 to 5, 1 being not well at all and 5 being really well, how well do the nurses complete the verbal portion of the handoff?
5 4 4 4.34
5. On a scale of 1 to 5, 1 being never and 5 being always, how often do the nurses open the electronic chart for review during the transfer process?
3 2 1.5 2.16
6. What percentage of the time do you think the nurses open the electronic patient chart during the transfer process (to review with the other nurse)?
These interviews are not directly related to the performance gap, which is why they are not coded.
Follow-up Interviews (Intervention ERIH)
The purpose of these interviews is to help the team determine if the ERIH will eliminate the performance gap.
Questions Interviewee Response
Our team noted that there is an
ERIH area in the EHR at HC Regional
and the claims are that this holding
area eliminates the need for nurses
to do the orders management
process when they transfer a
patient from the ER to an inpatient
unit. Does the ERIH eliminate the
need for nurses to do orders
management during transfer?
Follow-up:
Based on what you have seen, does this eliminate any risk associated with possible human error during the transfer process (related to orders management)?
Do you know why Holy Medical Center chose not to include the ERIH in their system build?
Do you know if Holy Medical Center has the ability to add this functionality to their system?
Orderset Liaison Yes. I used to be the primary support person for the ER at HC Regional
and I used to work in the ER at HC Regional and having the ERIH makes
the orders just go away. The patient starts with new orders when they
transfer.
Yes – I am extremely familiar with the functionality and it literally dumps
the orders (they are obviously retrievable and a part of the permanent
record), but in the nurse’s mind, it is much more like the “old” paper
process. They are essentially turning the page.
No, I am not sure why they chose not to use it. My understanding is that
they had the option to use it, but chose not to.
I do not know at this point what it would take, we could research that and
find out.
Clinical Informatics
Specialist (assigned to
support the ER at HC
Regional Medical
Center)
Yes, that is accurate; utilizing the functionality of the ERIH allows the
orders to go away upon transfer or “admit” to an inpatient unit.
There is essentially no risk, as there are no orders to manage. The ER doc
talks to the inpatient doc and they coordinate – the inpatient doc puts in
new orders, but can still ‘view’ the ER orders, if necessary.
I don’t know for sure, but most things are political. I am thinking they
came up with a process they thought worked for them and went with
that.
I do not know – I am sure it is there in the background. I don’t know what
Major trend is large data points that will be addressed by interventions
Minor trend is minor data points that should be noted or used for future
Information
Instrumentation
Motivation
Data 62 overall pieces of evidence that causes are
steaming from data issues in the environment. Data extracted from 11 interviews
Resources 24 overall pieces of evidence that causes are steaming
from resource issue in the environment. Data extracted from 11 interviews
Incentives 3 overall pieces of evidence that causes are
steaming from incentives issue in the environment. Data extracted from 11interviews
Environment
Major trends:
Inadequate information about roles and responsibilities of the process was found in 17 pieces of evidence extracted from 10 interviews
Evidence of trend found in interviews:
#of comments
Trainer D 2
Trainer P 2
RN Director 1 1
Nurse 2 3
Nurse 3 2
Physician Liaison 1
Orderset Coordinator
1
Clinical Educator 2
Charge nurse 1
Nurse 1 2
Trainers P comments: They can do some orders management over the phone with the doc, but it is really the job of the Doc, so we don’t go
Major trends: Lack of time to complete the EHR was found in 7 pieces of evidence extracted from 7 interviews
Evidence of trend found in interviews
#of comments
Trainer D 1
RN Director 1 1
RN Director 2 1
Nurse 2 1
Nurse 1 1
Nurse 3 1
Charge Nurse 1 RN Director 1 comment Time can be a barrier – pressure to get the patient transferred out. This is mostly related to the transfers that come to us from the Emergency Department. RN Director 2 Comment : What the nurses need is More time – not to feel so much pressure about time. Trainer Comments D: I don’t know why they chose to do that. It is a huge problem because the ER nurses don’t have time to clean up the orders, yet it is
Minor trend: No consequence for poor performance was found in 3 pieces of evidence extracted from 3 interviews
Evidence of trend found in interviews:
#of comments
Nurse 2 1
RN Director 1 1
RN Director 2 1 Nurse 2 comments: If I don’t clean up the orders then someone on the floor calls us, other times they just figure it out RN Director 2 comments: The process implemented is not the RN’s fault. We don’t punish people unless they are intentionally doing something that will harm the patient. RN Director 1 comments: If they don’t do the chart right, their peers will let them know The receiving nurse will call the transferring nurse and ask for clarification which takes time. If there is a real problem nurses will communicate to the
over it too much Trainer D comments: A lot of orders management falls on the Doc, so we don’t hit orders management too hard in the classes. RN Director 1 comments: Also, nurses don’t make changes to orders- that is supposed to be the role of the doctor. I think some nurses feel like that by deleting the orders they are practicing outside their scope Nurse 2 Comments: Drama around roles. Charge nurse is supposed to do the admit orders so it can be unclear about who is supposed to do the other pieces. Nurses, in theory should discontinue and complete orders but they don’t’ always do it. Nurse 2 comments: We don’t really have a system in place to check to see if the orders are taken a care of before they are transferred. Not sure if anyone knows whose job it is. It is not the MD’sjob in the system, they don’t have time. The nurses should be doing it but they aren’t, they may not know it is their responsibility. Nurse 3 comments: Nurses are supposed to clean up the orders. I don’t think it probably doesn’t always happen. It can be confusing as who is supposed to do what. Nurse 3 Comments. The process ( of who should clean up orders) hasn’t been explained; maybe it has but I have forgotten. Nurse 2 Comments: I would not say they are all comfortable with discontinuing orders. Physician Liaison comment: I think there is so
supposed to be their job. Nurse 2 Comments: The EHR has pretty much slowed everything down (note: nurse has little to no experience in computerized physician order) Nurse 3 Comments: I have quite a bit of experience with electronic chartings so I don’t think it has really changed the time it takes me. It may take a little more time but not much. Charge nurse comments: It is the nurses job, well I’m pretty sure, but it doesn’t get done like it should. I think some of them know, but don’t have the time and others are just not sure what is their job and what is the role of the doctor. Nurse 1 comments: It takes a lot more time – a ton more time! I hate it. It is not intuitive, like they said it would be Major trends: Lack of adequate job aids was found in 6pieces of evidence extracted from 6 interviews
Evidence of trend found in interviews
#of comments
RN Director 1 1
Trainer P 1
RN Director 2 1
Nurse 2 1
Nurse 3 1
Nurse 1 1 RN Director Comments: Job aids come from somewhere… not sure where and we are expected to get them to the nurses. They are difficult to understand
much going on that no one is clear on what their role is. Orderset Coordinator Clinical Informatics comments: The nurses should be doing it, the actual in the computer piece. The obviously consult with the MD’s but they should be completing and discontinuing orders. Clinical Liaison comments: Nurses should be cleaning up the charts I suppose. Really I think the doctors should do it but everyone says that since they won’t it falls on the nurses. The nurses should clean up after they have consulted with providers what orders should and shouldn’t continue. Clinical Educator comments: Nurses should do the orders management. It can be tricky to know who should supposed to do what. Since I did the observations I realized although I said yes they are doing the orders management I should have said they are “kind of doing the process” Charge nurse comments: It is the nurses job, well I’m pretty sure, but it doesn’t get done like it should. I think some of them know, but don’t have the time and others are just not sure what is their job and what is the role of the doctor. Nurse 1 comments: I don’t discontinue stuff, I just know what he (the MD) wants me to do. I give the report of what has happened when I call the floor nurse; they can figure things out from there. Am I supposed to be cleaning up the orders? I suppose it might be my job, but I just worry about the ER orders and then I give info I have to the floor nurse.
and way too long. Trainer comments: There are job aids in Sharepoint. We do tell them in class how to access the job aids. There is also a Guide Me function in Cerner now. This is really high-level stuff from the parent company, but it is new and can be helpful. RN Director Comment: They need simple job aids with bullet points – do this, do this, do this. Not 15 page documents Trainer P comments: There are at least 100 job aids. Probably too much info for them there and I have been told hard to find exactly what they need. Nurse 2 Comments: I have no idea where the job aids are. I don’t really have time to refer to something that is that long. The job aids are long. Nurse 3 Comments: I know they showed us where they are but I don’t remember. Nurse 1 Comments: I have no idea where the job aids are. I supposed they told me, but I don’t know where to find them. I think they put them on a board or something. Not sure. Observations: 4 out of 4 nurses did not use job aids Minor trend: System not easy to use RN Director Comments: During the transfer process, the information is easier to see. The nurses can see everything that was done on the patient in the other unit.
Trainer D Comments Nurses feel some of it is out of their scope of practice Trainer P Comment: Some of the more tenured nurses also feel like it is outside their scope of practice. I tell them not to think of the Orders tab as the “orders” tab – they look at that as physician-driven Major trends: Lack of adequate feedback was found in 10 pieces of evidence extracted from 9 interviews
Evidence of trend found in interviews
#of comments
RN Director 1
Observations 2
Trainer 1
Physician Liaison 1
Clinical Liaison 1
Charge Nurse 1
3 Nurses 3 Lack of feedback from Director to RN RN Director 2 comments We need to reiterate the message that it is okay (in reference to the earlier comment about it being the doctor’s job) to clean up the orders – we need a clean slate when the patients come to our floor. This helps everyone do their job better. Lack of feedback from Doctor to RN Observations 2 out 4 nurses did not talk to the provider during the orders management process
RN Director Comments: there is also SO much information on a chart. It is difficult to sort through all the information. Nurse 3 Comments: Finding information can be tricky but I have lots of experience so I am fine. Observations: Computers are not in the patients room must go somewhere else Nurse 2 comments: We don’t really have a system in place to check to see if the orders are taken a care of before they are transferred.
Trainer Comment: I actually don’t know which site liaison there would help with RN issues. I am not sure they know who to contact there. I don’t think the liaisons understand their own roles. Lack of feedback to RN’s about charting audits
Physician Liaison Comments: Since most of our audits are informal, and more for the purpose of gathering information, I don’t do anything formalized with the information. My primary responsibility is to work with providers (physicians and mid-levels), and if there is something that is directly affecting them, it becomes my problem to solve. At this point, I just noted the information and may bring it up to colleagues if it seems to be an issue. Clinical Liaison Comments: I did the audit at your request. We did note the issue and will bring it up at IOT (a meeting that involves people from the corporate office as well as local leaders – they assign problems for resolution and report on those at this meeting). We have brought it up before, but the other location does not always have a representative at the meeting. Charge Nurse Comments: I do bring chart audit info up at huddle, but at this point I think I need the process and the responsibilities clarified myself. Nurse #1 Comment: Nurses If you don’t clean up the orders before you send the patient to the floor, what happens? Sometimes they call us to clarify, other times, nothing
Nurse #2 Comment: If you don’t clean up the orders before you send the patient to the floor, what happens? It depends. Sometimes the floor calls us – other times they just figure it out Nurse #3 Comment: Nurses If you don’t clean up the orders before you send the patient to the floor, what happens? They seem to figure it out Major trends: Lack of information about support was found in 7 pieces of evidence extracted from 7 interviews This is also an information problem.
Evidence of trend found in interviews
#of comments
RN Director 1 2
Trainer P 1
RN Director 2 1
Nurse 2 1
Nurse 3 1
Nurse 1 1 RN Director Comment: We don’t know who to contact to implement changes or who to talk to about training. RN Director Comment: I don’t know what the relationship between the hospital and the CID
should be. I don’t even know who to contact for training support or questions Trainer Comment: I actually don’t know which site liaison there would help with RN issues. I am not sure they know who to contact there. I don’t think the liaisons understand their own roles. RN Director Comment: The only support we have now for training, other than the updates from corporate, are the Super Users that are on our floors. However, they have gone back to their jobs, so they are not receiving ongoing training in the system. Nurse 2 Comments: We would go to Shellie (someone local that does not have the primary responsibility for training). I may call them (Main Location) if I needed help but I don’t know how to get a hold of them. Nurse 3 Comments: I don’t think we have a formal help line or anything. I maybe call someone if there was a number for support. Nurse 1 Comments: If I had problem would I call the help desk? No, not really. The help desk? Not if it isn’t about the computer. Hmmm…. No, I would just ask the charge nurse for help. I don’t know if I really care.
Knowledge 21 overall pieces of evidence that causes are
steaming from knowledge/skill issue from individual
Data extracted from 11 interviews
Capacity Motives 29 overall pieces of evidence that causes are steaming from motive issue from individual
Data extracted from 11 interviews
Individual
Major trends: Lack of adequate confidence to clean up orders .5 pieces of evidence extracted from 4 interviews
Evidence of trend found in interviews
#of comments
Trainer D 1
RN Director 1 1
Nurse 2 2
RN Director 2 1
RN Director 2 Comments: The training was all done in a “fake” environment. It was all theoretical. We were not able to use a live system and practice on real charts. Trainer D comments: There is just a lot of information and they were nervous about things. RN Director 1 Comments: A lot of people are tactile learners and will only learn by actually doing it they didn’t get this. Nurse 2 Comments: In training they skipped over this (the role of who does clean up) so not sure if it was very clear Nurse 2 Comments: I would not say they are all comfortable with discontinuing orders.
Major trends: ** This is a diffusion effect steam from a lack of information
Inadequate motivation by nurses to clean up the orders. 8 pieces of evidence extracted from 7 interviews
Evidence of trend found in interviews
#of comments
Trainer D 1
Trainer P 1
RN Director 1 1
RN Director 2 1
Nurse 1 1
Nurse 2 1
Nurse 3 1
Trainer D comments.. The why we discussed was that when there is an order it generates a task for the nurse. If you don’t clean up the orders, as a nurse, you are actually creating more work for yourself by there being more tasks generated. They understand the why, but I don’t know if they buy into it. Trainer P Comments: Nurses see Order Management as “not my problem”. The transferring nurse see that the receiving nurse will be responsible. RN Director 1 Comments: The RNs are mourning the loss of paper, particularly those that have been in practice for a long time, but the information is flowing and they understand the purpose. The purpose has been reached, but it does not mean that they are not still adjusting to the huge change.
Minor trend: Lack of computer skills RN Director Comments: They are still great nurses, but they computer has thrown them off and made them question themselves. Some of the newer nurses are better at the computer piece of things, but they still need to build their skills in other areas. Trainer D Comments Some RNs are more comfortable with computers. Some of the more tenured nurses also feel like it is outside their scope of practice. RN Director 2 Comments: I think some of the RN’s do not feel confident in their computer skills Nurse 2 Comments: I am comfortable with the computer. But this is just a totally different system than I’m used to. Nurses Comments: I am a geriatric nurse. It was humiliating to be in class with these young kids just zipping around in the system. I felt like I was back in school. It was awful. I am figuring it out though and I don’t think that is the case for most nurses. I don’t really think it is that big of an issue for most of the nurses in my department. Mostly me! 4 Nursing Observations showed all nurses using the computer with proficiency
RN Director 2 Comments: it was a top down initiative, but the nurses do not care about the WHY. I don’t know that they fully understand the purpose RN Director Comments – sometimes they don’t see the need to do the orders management (when transferring). Nurse 2 Comments: We went to EHR because it was an initiative from the corporate office. To meet certain standards with the fed government they had to go electronic. Nurse 3 Comments: We went to EHR because it part of Obamacare. Nurse 1 Comments: It doesn’t really matter to me. They had to – we can’t go back. The government is telling them they have to. I understand why, and I know we can’t go back. They why doesn’t really matter, I just want to make sure my patients are taken care of. Major Trend: ORG ** This is a diffusion effect steaming from a lack of information and inadequate resource support from sister company. Distrust is coming from supervisor roles primarily Distrust between Main Location/Other Location or Between Departments (10 pieces of evidence)
Trainer D comment: We rarely get calls from the other location. The majority of them are system access requests (password help, etc.). the other location is typically dismissive and rude to the main location people anyway. They are not open to “help” from main location – it is like they have something to prove. They don’t listen when I try to help them RN Director comment: The system used to work for us, now we work for the system. Cerner designed the system for Evidence-Based Practice RN Director comment: I don’t know what the relationship between the hospital and the CID in he main location should be RN Director comment Another issue with the training was that the people doing the training were not nurses. They were non-clinicians, so their brains process differently. RN Director comment: It has been a very difficult
cultural change.
Clinical Liaison I don’t think they are doing it in the
other location like they should be. It is probably
something that was lost in translation during the
whole go-live process. We may need to go back and
clarify things to them.
RN Director comment: We can no longer make
changes based on our needs.
RN Director comment We can make requests, but
there are not guarantees as to if the changes will be
made or not
RN Director comment: The system is not bendable,
the culture has to bend to fit the system
Trainer comments: The problem is, in the other location, they chose to do a different process than main location on transfer from the Emergency
Conduct the HPT process in a way that is systematic
A systematic HPT process is a carefully planned, deliberate effort that uses appropriate methods of problem definition, data collection and data analysis to minimize the likelihood “errors and omissions”, that is, of not discovering vitally important information regarding a performance problem and/or misconstruing what evidence is gathered. Rummler and Brache (1995) state that organizations are systems but that many managers of these systems fail to recognize customers, product/service or workflow. As nascent HPT professionals, we do not want to make this same mistake!
Therefore, to insure our assessment will be as systematic as possible, the Team applied the principle of the “Seven Ps”, Proper Prior Planning Prevents Pitifully Poor Performance to our efforts. Specifically, before meeting with the client, the Team:
● selected a Needs Assessment model – the Behavior Engineering Model (Gilbert, 2007) with additional perspectives and concepts suggested by Marker (2007) and Langdon (2000);
● evaluated the worth of the project by consulting with both Chyung (2008) and Gilbert (2007);
● consulted with the client on the importance of the project to the hospital by employing the Lean principle of the 5 Whys;
● assessed if the problem was truly a performance problem by using the questions from Harless (1987);
● located prior research into problems associated with patient transfers with hospitals (aka “handoffs”), systemic medical errors, and medical provider communications;
● adopted a structured process of data collection as recommended by Schensul and LeCompte (2013) consisting of open-ended as well as focused questions using key terms gathered from the literature, such as “handoffs” between providers or departments. (Friesen, White & Bryers, 2008). By starting with open-ended questions we identified key issues and site-specific language which we incorporated into more narrowly focused interviews and observations during subsequent stages of data gathering.
● used deductive reasoning, as per Schensul and LeCompte (2013) to synthesize the data; and
● used cost and benefit analysis, as well as consulted with the client on intervention recommendations.
The team had to adjust the plan as the team noted specific trends in the data, but by having a plan in place the team was able to focus on the data and the assessment.
Very early in the process, the team confirmed that the performance gap was not limited to a single person or shift of workers. For this reason, and consistent with HPT best practices, we quickly moved to study a larger context of peers, managers, processes and/or culture. Only by considering many inter-related factors in a systematic way can the root cause(s) of performance problems be found. As Tosti (n.d.) mentions, “[Determining] all the system factors that may impact the desired results [is the] KEY step in any improvement program”.
An overview of the transfer/admit process, as well as pre-existing conditions was also required since the client recently shifted from a very familiar paper-based medical chart to an Electronic Health Record (EHR). For these reasons, the team first explored the larger context of patient transfers, Electronic Health Records, and the directive that ER nurses manage the medical orders in the electronic system. The team uncovered numerous concerns related to information and incentives at the individual as well as environmental level. In other words, we uncovered evidence and possible causes of performance problems in four out of the six “cells” of the BEM.
Conduct the HPT process in a way that is consistent with established professional ethics
Team Healthcare conducted its on-site and preparatory efforts in a professional, ethical manner. We informed the client and all persons interviewed of our intentions and told all participants their involvement was voluntary. As suggested by the ISPI Code of Ethics (2002), the team masked individual identities to protect privacy as well as gather candid responses from hospital staff and managers. By doing this, the team was able to protect the client and keep their performance issues confidential.
The team requested to audit patient charts as well as observe nurses as they completed the transfer process. The audit would have allowed the team to understand what poor performance and exemplary performance would look like in the electronic record. Actually seeing the patient charts first-hand would have been optimal. Observations would have allowed the team to see nurses in action, actually performing the tasks related to transfer.
Due to HIPPA and privacy concerns voiced by the hospital staff, the team could neither collect nor see patient-specific information. Understanding that this request may put the client at risk, the team came up with alternate solutions that allowed the team to both keep the client’s trust and effectively complete the assessment. The ISPI Code of Ethics (2002) challenges professionals to show empathy for clients and their concerns; by formulating alternate solutions for our data collection, we honored this code.
Conduct the HPT process in a way that is consistent with established professional standards
Team Healthcare’s effort has met all relevant standards established by the IPSI for a Needs Assessment effort. Specifically, we have:
not accepted the initial assertion that the client had a “training problem”;
“pushed back” on the above issue and created the necessary conditions to gather data from various actors and stakeholders; and
analyzed data to uncover possible causes of performance problems that would not be solved by additional training.
Because the team pushed back, the client was able to see alternative solutions to the performance problem. Through this assessment process, the team believes it added value to the client’s organization by offering solutions to help them move to where they needs to be in the future and focus on measured performance based on proven results (ISPI, 2002, p.1).
In support of the ISPI Code of Ethics (2002), Team Healthcare set clear expectations with the client about the systematic process we planned to follow, before proceeding with the investigation of the need. The team established the following boundaries with the client:
obtained official written permission from our client to conduct our study;
agreed to keep conceal the identity of the organization and interviewees;
agreed to keep the client informed of key findings before moving to each process; and
established a professional relationship with all parties involved when collecting data.
Furthermore, one team member that previously worked for the client removed herself from the data coding and synthesis process due to her fear that she may not be able to be objective in the process. Remaining objective is directly in line with the ISPI Code of Ethics (2002).
Align performance improvement solutions with strategic organizational goals
Our findings will help the client understand that solving the performance gap will require a multi-faceted solution well-beyond “more training”. The team aimed the solutions at filling the performance gap, which will help the hospital achieve their organizational goals. The primary concern of the hospital is patient safety and providing excellent patient care. The interventions selected by the team and the client align with these goals. The team believes if the hospital implements their solutions, they will be able to preserve patient safety, avoid expensive litigation due to medical errors, which will help them also fulfill their mission of “serving the poor and underserved” by preserving their resources for such.
Make recommendations that are designed to produce valued results
Our recommendations, summarized above, reflect a “sweet spot” between the risks, costs and benefits of doing nothing, contracting for more training, or calling for elaborate, costly organization development consulting. As per Gilbert (2007), it makes no sense to spend more money fixing a problem than is gained by even the most successful intervention.
Since the cost of a single legal settlement for malpractice, wrongful death or personal injury can easily top $1M dollars, the modest costs of the team’s recommendation are clearly cost-effective and consistent with the “no resources” available to close the performance gap.
Collaborate effectively with others, in person and virtually
Team Healthcare members live in three different time zones and have collaborated across space and time by using tools such as Google hangout, Skype, conference calls, email and the Lotus Notes database.
The client and two members of the team are located in Boise Idaho. One team member is a former employee of the hospital and has acted as our single point of contact and tireless on-site representative.
The team determined that in order to verify a performance gap, it would be necessary to observe nurses in the process of a transfer. This proved logistically difficult since ER-to-Inpatient “transfers” do not happen that often. For this reason, the team prepared an observation form which the clinical educators used to make observations. This approach not only allowed the team to gather data, it built trust between the client and the team.
Communicate effectively in written, verbal, and visual forms
Team members have a diverse set of professional skills. We made deliberate efforts to couch our questions to clients in language consistent with a hospital setting, in general, and to this facility in particular.
Team members consistently interacted in ways intended to strengthen inter-team cooperation and communication.
Because only one of us was able to visit the hospital or interact with staff by telephone, the rest of us felt a duty to take on a much of the other work as possible. We kept in touch with each other via email almost daily and held conference calls at least once a week and often several times a week.
Use evidence-based practices
Team Healthcare collected mostly qualitative data from both unstructured and focused interviews and 3rd party observation. This raw data was coded and scored to enable some level of quantitative measurement of the problem space. For example, by counting key words and phrases used by respondents, we learned that the performance problem has deep roots in both the information and incentive columns of the BEM.
We employed data coding and analysis techniques recommended by Schensul and LeCompte (2013). Specifically, we collected data from interviews, 3rd party observations, and training documents, reviewed and color-coded them into BEM-based “cells”, then listed the exact words which justified each classification. We were them able to rank each of the BEM “cells” to identify those most represented tin the data gathered from various sources.
During the intervention selection, the team consulted several sources, both to guide the team in the selection process.
Contribute to the professional community of practice
If our client agrees, we will convert our project report into a “Tale from the Field” and submit it to PerformanceXpress with the hope that our efforts, however rudimentary, can help others facing similar problems.
In addition, we learned how valuable it is to gather data from multiple sources, job titles or organizational roles. Triangulation is a powerful tool that we will take our respective places of work.
We also learned how important it is to consider the cost of as intervention as well as its appropriateness. It makes no sense to spend $1 to fix a 10 cent problem!