How evidence-based clinical documentation gives time back to nurses

August 21, 2018 |  Nursing, EHR, Implementation, Patients

 how-evidence-based-documentation-gives-time-back-nursesAs nurses, we know that patient care is not one-size-fits-all. Every patient has unique needs when it comes to determining the best course of treatment. But even with all of those unique patient needs, clinical documentation can be structured so that each patient gets the right individualized care while nurses use a standardized reporting system, ultimately saving nurses’ time.

At Hospital Corporation of America (HCA), we recently implemented a redesigned EHR system across 170 facilities in 20 states, following an evidence-based design that aligns minimum documentation requirements with ideal workflow. As a result, we’ve saved up to two hours spent on documentation per nurse, per shift. HCA implemented this new documentation system over the course of two and a half years, dividing our hospital network into 14 divisions with a number of hospitals in each.

As we’ve rolled out the system throughout the organization, the process has followed the same basic outline: We start with leadership training and staff pre-work sessions, hold “boot camps” where nurses get their hands on the new system, train super-users and experts who provide ongoing technical support, and finally go LIVE with the new system.

This has been quite a learning experience for our evidence based clinical decisions team — after our first go-LIVE that covered just one hospital, we received a huge binder of change requests. We took all that data, went back to the drawing board, and worked on perfecting the content before restarting the implementation about six months later.

Thanks to that deliberate approach, we’ve seen the process go more smoothly — during go-lives, our team would sit in the HCA command center to provide support, and for many of the later implementations, we received no phone calls from our hospitals asking for help.

Our end user nursing staff looked forward to the new documentation being in place, and they were excited to share their experiences on social media — how often can we say that about implementing an entirely new system?

Guiding principles

When HCA embarked on this project, we first established the principles that would guide the development of a standard documentation system.

Among the most important guidelines were following evidence-based decision-making, having clinicians define the content they would use, and maintaining a patient-centered focus while avoiding over-building the content.

From the administrative perspective, we took the approach of having a small design team and large review team, which made the design process much more efficient. We also maintained the focus on evidence-based practice, and using the software as designed to minimize maintenance and enable more timely upgrades.

Another key decision was to use a standardized, coded, patient care terminology, the Clinical Care Classification (CCC) System. CCC is based on just four healthcare patterns, with 21 care components, 176 diagnoses, and 804 interventions that focus on the “essence of care,” meaning the specific actions that a nurse takes with the patient in the clinical setting.

By streamlining our CCC, we also created a simplified Plan of Care (POC) that keeps the focus on the patient while routine care, individualized considerations for care, and physician ordered nursing interventions are maintained in other areas of the EHR.

We started implementing the new POC first, because we found that making the cultural shift was just as big of a project as everything else related to the documentation update — and in the end, it made a huge difference for our staff and our patients.

Routine and Individualized Care

One challenge HCA faced was the question of how to delineate routine and individualized care within the updated EHR documentation.

Routine care, as the name implies, is common among all patients. We outlined the required routine care elements under four major areas: Assess, Perform, Teach, and Manage in accordance with the CCC framework of nursing interventions and actions.

From intake assessment to care management post-discharge, HCA nurses complete a uniform set of tasks for all patients, and add a small set of data to the Plan of Care to inform later clinical decisions.

At the same time, nurses gather individualized information, like cultural and spiritual considerations, hearing or sight impairments, legal considerations, assistive devices, substance abuse, living situations, and educational needs. This can assist caregivers with determining the best treatment for a particular patient.

This individual information is not entered into the POC or associated with treatment goals; it remains easily accessible via the history by any provider who may need it.

Streamlining nurses’ workflow

Possibly the biggest change we made to our documentation related to the POC is we eliminated query links. This ended the practice of nurses automatically adding problems in high-risk cases, which only served to make the POC more complex.

One of the other major changes that HCA made to our nurse documentation was separating specialists’ workflow from the interventions. So, for instance, nurses no longer ask dozens of questions from a nutritional questionnaire, since dieticians are trained to be in tune to dietary workflows. Instead, nurses ask three to five questions in nutritional, functional, and mental health screenings that provide enough information to identify the need for further assessment or intervention by specialists.

This one change has resulted in significant reductions in the time that nurses spend on screenings, and in the time it takes to bring in the specialized resources a patient needs.

Reflections on the process

When I look back at HCA’s experience in rolling out this streamlined documentation, one thing that stands out is the cultural change that it represented — our nurses needed a lot of reassurance that they were collecting and recording enough information.

Think about it — from the time we’re in school, nurses are being trained to document everything, even to the point of making a note that they walked into a patient’s room. So, when they are presented with a new system that eliminates a lot of documentation and pares down the amount of data they need to record, it’s a big shift.

By rolling out the new system in a deliberate and informed way and ensuring leadership buy-in early in the process, we’ve improved the way nurses work.

In response, they’ve praised the new system for how it gives them more time for patient care — and I think that’s the best way to sum up the impact of this new system; to share the feedback that our nurses provided after making the switch:

“I feel a big weight off my shoulders stressing about data collections, midday and end of shift notes,” wrote one at Riverside Community Hospital. Said another: “I feel like a nurse again, treated like a professional. I am more able to chart real time, doing the little things that before I forgot or just didn’t get to, and that makes me want to go the extra mile.”

This is the most visible proof that our new approach to documentation is changing nurses’ lives by reducing the time they spend at the computer  — giving them more time to help patients.

Learn more from attendees at our Nurse and Home Care Forum about navigating the new healthcare paradigm.

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Written by Sarah Michel, MBA, BSN, RN, NE-BC, Director of Nursing Innovation, Hospital Corporation of America

For the past three years, Sarah has been leading evidence-based clinical documentation for HCA. The initiative began with one alpha site in February 2016 and two FTEs from the Clinical Services Group dedicated to the project, and now covers 170 facilities LIVE on MEDITECH. Sarah holds an MBA in Healthcare Management from Regis University.
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