Survey Results Best Practices in Implementing Nursing/Interdisciplinary Documentation Systems Susan K Newbold, [e-mail]

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Survey ResultsBest Practices in Implementing
Nursing/Interdisciplinary Documentation
SystemsSusan K Newbold, susan.newbold_at_vanderbilt
.edu
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• Study Conducted By
• Kathleen Kimmel, RN, BSN, MHA, CHE, FHIMSS,
  McKesson
• Susan K Newbold, PhD, RN-BC, FAAN, FHIMSS,
  Associate Professor, Vanderbilt School of Nursing
• Randy OSteen, RN, Executive Director Unity
  Project, CHRISTUS Health
• Gina Sauls Morgan, MSN, RN, Graduate Nursing
  Informatics, Vanderbilt School of Nursing

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Agenda

• More Findings
• Integration and Interoperability
• Metrics
• Content and Standardization
• Adoption
• Devices
• Outcome
• Summary

• History
• Purpose
• Methodology
• Findings
• Background
• Leadership
• Clinical Transformation
• Project Management and Project Design
• Implementation

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• History

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Request for research

• HIMSS Annual Conference 2006 members of the
  HIMSS Management Engineering and Process
  Improvement (ME/PI) Task Force and the HIMSS
  Nursing Informatics (NI) Task Force gathered to
• Answer a request for interdisciplinary tools
• Create a introductory presentation on ME/PI to NI
• Establish adaptable framework for implementing a
  point of care/clinical documentation system
• Identify best practices for nursing/interdisciplin
  ary documentation implementation

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• Purpose

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Why is this research important?

• Add to knowledge base currently large amount of
  anecdotal evidence in the literature on
  implementation best practices -- the result is a
  patchwork quilt
• Establish best practices
• Creation of a standardized survey/research tool
• Validate current beliefs and provide additional
  insight
• Collect tools and enrich our HIMSS NI repository
  http//www.himss.org

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• Methodology

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• Defined exemplar
• Exemplar/advanced organization is one where the
  nursing documentation system is live, fully
  deployed, and used broadly across the
  organization
• Identified exemplar organizations
• Vendors were asked to identify three
  organizations that met the advanced organization
  criteria

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Interview Tool

• Background
• Leadership
• Clinical Transformation
• Project Management and Project Design
• Implementation
• Integration and Interoperability
• Metrics
• Content and Standardization
• Adoption
• Devices
• Outcome

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Timeline

• Peer review from the NI Task Force, the ME/NI
  Task Force and the NI Committee
• Engaged faculty sponsor, Dr. Susan Newbold and
  willing student, Gina Sauls
• HIMSS established research guidelines, policies,
  procedures
• Conducted 15 live interviews
• Submitted responses stored in data collection
  software (from CHRISTUS Health)

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• Findings

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Exemplar statistics

• Study conducted April August 2007
• N15
• 80 were not-for-profit community based
• 78 were integrated healthcare systems
• 33 used decision support applications
• 36 were Magnet accredited
• Average bedsize gt250
• Live for gt 3 years
• Implementation of nursing documentation system
  took 1-2 years

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Mix of Applications In Use
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Leadership and proper orchestration is crucial

• Main driver for change was Patient Safety
• Main sponsor was CEO
• Governance collaborative sponsorship
• Sponsors/Leaders were visible during go lives and
  rounds
• 73 used project charters
• 73 used scope documents
• 67 created an organizational chart for their
  project
• 53 developed project vision statements

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Main Drivers for Implementation
Patient Safety a key driver in 73 of Clinical
Documentation projects
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Primary Sponsors for Clin Doc Projects
Where are the CNEs?
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Use of Standard Project Management Tools
We have work to do!
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Clinical transformation describes how the climate
changed during the migration

• Found significant variation between organizations
  clinical transformation processes
• 71 used consultants
• 86 included process changes during training
• 87 performed a gap analysis
• 100 stressed staff and ancillary department
  involvement with process redesign
• Reduced variation to support patient safety

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Project management leadership was mixed

• Project management led by
• Nursing 8 IT 34 Both 58
• 100 had steering committees, meeting at least
  monthly interface with shared governance
  councils
• 71 had project (program) offices
• Full and part time FTEs ranged from 5 to 110, a
  lot of fluidity
• Budgets varied
• 50 used capitalized budget (as per SOP 98.1
  guidelines)
• 42 used operating budgets
• 8 used training budgets

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Requirements for Superusers

• 100 used Superusers, but requirements varied
• 86 had specific requirements and job
  descriptions
• 57 were selected by managers
• 43 were allowed to self select
• Scheduled support by Superusers varied average
  identified was 2 weeks

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Implementation Pilots passé Modified BIG BANG
is preferred

• 50 used BIG BANG with modified rapid rollout
  preferred
• 36 used pilot with sequential department rollout
• 14 used a pilot with house-wide rollout
• ICUs were typically last
• Multi-facility organizations rolled out in
  consecutive phases
• Note Implementations improved with each go live
  at a new facility

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Levels of integration and interoperability

• 93 integrated with Radiology and Lab
• 80 with Registration
• 66 with Scheduling
• 63 with Pharmacy
• 40 with Therapies (i.e. PT, OT)
• 33 with Surgery
• 33 with Ambulatory
• 33 with Oncology Radiation and Chemo
• 27 with Labor and Delivery

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Applications Integration
Only 60 integrated with Rx and 80 with Lab
what about Patient Safety?
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Baseline metrics and benchmarking falls short

• Usage metrics are used to determine educational
  needs for the various nursing units
• Measuring benchmarks
• 64 collected both before and after project
• 29 only collected metrics before
• 7 only collected metrics after
• 79 followed the JCAHO requirements as part of
  their metrics
• 64 measure metrics quarterly

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Nursing languages not a priority, standardization
is

• Nursing Languages - 20 used customized content
  and standardization using nursing vocabularies,
  NIC/NOC and NANDA were identified
• Standardization of electronic care planning forms
  across an enterprise - 87 used standardized
  electronic care planning forms

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Adoption advice

• Downplayed that it is a new computer system
  versus a care provision tool
• 100 established a communication plan
• 43 reported barriers with training
• 14 reported barriers with devices

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You can never over communicate!

• 29 reported physician resistance as a barrier to
  adoption getting over this hurdle required
  communication (listening getting feedback),
  being responsive, educating, and assisting them
  with their learning curve
• Ancillary department adoption suffered from a
  lack of devices

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Best practices for devices combination!

• 93 had a combination of devices
• Computers on wheels (COWs) aka workstation on
  wheels (WOWs)
• 93 have a number of all-purpose devices that
  physician, ancillaries, and nurses can use
• 93 recommend one device per one nursing staff
  member
• Handhelds were not favored because of perceived
  bulkiness

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Outcome Interdisciplinary care has been
achieved!!!

• 93 report that nursing ancillaries are sharing
  patient data without duplication of information
• 86 of physicians are viewing documentation on
  line
• Data sharing varied some reported viewing vital
  signs, while others were also viewing nursing
  documentation

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Lessons learned

• Communication is critical!
• Leadership during go live is a must!
• Participants expressed a need for greater rigor!
• Establish and measure metrics before starting
• Better project management, especially maintaining
  time lines
• More training root cause analysis showed lack of
  education was a culprit
• Identify responsibilities and expectations with
  vendors

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Next Steps
Expansion of HIMSS Nursing Informatics website to
include new tools gathered from exemplars
requested by December 2007 and now on the HIMSS
site, www.himss.org

• Recommendations for further research
• Issues related to Nursing language adoption
• Discussing the role of nursing executives in
  implementation

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Our sincere thanks to

• HIMSS NI Committee, NI Task Force, ME/PI Task
  Force and the entire NI/ME Work Group
• Vanderbilt University School of Nursing Susan
  Newbold, PhD and Gina Sauls Morgan, Graduate
  Student
• Thank you to the following
• Aurora Health Care Avera McKennan Hospital
  Baptist Medical Center Cerner The Children's
  Hospital of Denver Citizens Memorial CHRISTUS
  Health Eclipsys EPIC Evanston Northwestern
  Healthcare GE Medical Health-First Health
  System Memorial Healthcare System Hollywood
  Florida MemorialCare Medical Centers McKesson
  MEDITECH Norton Healthcare New Hanover Regional
  Medical Center Pikeville Medical Center
  PinnacleHealth System Siemens Solaris Health
  System Summa-Health System Wake Forest
  University

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Questions?
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Survey ResultsBest Practices in Implementing
Nursing/Interdisciplinary Documentation
SystemsSusan K Newbold, susan.newbold_at_vanderbilt
.edu