Slashing Documentation Time at Summa Health System
Efficient work design is at the core of several initiatives that have helped reduce documentation at Akron-based Summa Health System. These efforts began back in the 1990s, when Summa leaders set out to revamp a number of their manual documentation processes in preparation for automation. Recognizing the huge investment required, system leaders didn’t want to automate inefficient processes.
Time studies showed that Summa nurses spent 25 percent to 40 percent of their time on documentation activities. Some nurses relayed stories of documenting a diagnosis in 16 different places. Nurses were also entering patient data, such as pain status, on several different forms. Summa was able to scrap 80 forms through its documentation redesign. Many forms had been duplicates. In addition, documentation time was reduced to 10 percent to 20 percent of a nurse’s day, just from manual redesign alone (Keeping Patients Safe: Transforming the Work Environment of Nurses (National Academies Press, 2004).
Waste Not, Want Not
Targeting waste is one of the key principles of
“Lean” organizations like Summa, which aim to reduce or simplify activities that
don’t add value. Work design is a process organizations use to examine and
transform the ways that staff members work. It involves several steps, including
the following:
•Gather information through observation and interviews.
• Review data, such as patient and nurse satisfaction, organizational charts, job descriptions, and error reports.
• Identify problem areas through methods like root-cause analysis. In root-cause analysis, staff asks questions to uncover the cause of a problem: Why is this process inefficient? What factors are contributing to duplicate documentation? What processes are adding to the problem?
Going with the Flow: One Example
Leaders at Summa set out to create
flowcharts to identify areas for improving work flow and reducing documentation.
For example, during its redesign, Summa identified that its procedure for
labeling and processing laboratory specimens was cumbersome. Nursing staff
wasted time handwriting lists of laboratory patients each day, and they needed a
way to consolidate their work. “Automating that process required a lot of
retooling,” says Jill Hazelton RN, MSN, clinical information system analyst. “We
had to ask questions like: When will the labels print? How will the labels get
to the bedside?”
To help them refine how they printed lab labels, representatives from nursing, laboratory, and clinical IT created work-flow charts to map out the current process. Now, the process is more streamlined. All morning round labels are automatically generated as a single set of consolidated labels, which are printed directly to the nursing unit. The process of ordering and collecting the lab items within the computer system eliminates the need for handwritten documentation within the paper-based nurse’s notes.
Standardizing Order Sets
In January 2007, Summa completed a
two-year rollout for computerized physician order entry (CPOE). Also rolled out
in this electronic health record were online lab results and electronic entries
by nursing for allergies, weights, vital signs, and home medication history.
Mobile computer carts enable nurses at Summa to access patient data, automate
safety checks, and communicate with the rest of the care team without leaving
the patient’s bedside.
Order sets, which are integrated into the computer software, have helped Summa improve quality and financial outcomes. These automated pathways facilitate compliance with using approved, evidence-based protocols. Prior to adding CPOE, standardized order sets were used only 13 percent of the time. “Today, order sets are used 90 percent of the time at Summa,” says Linda Gleespen, RN, BSN, lead quality and clinical analyst.
A recent study in Computers, Informatics, and Nursing suggested that using CPOE might be the key to reducing documentation burden because orders are automated. That’s been the case at Summa as well. “The expectation is that the physician places orders directly into the application, so the nurse doesn’t have to transcribe handwritten or preprinted paper order sets into the system,” says Gleespen. “Additionally, because orders are automatically sent electronically to applicable departments such as the lab, the need to complete paper requisitions is eliminated.”
Summa currently has about 100 different order sets in its CPOE system. For example, order sets for stroke include measures such as deep vein thrombosis prophylaxis and neurology consultations. In stroke care, an evaluation of 131 patients with a diagnosis of stroke was conducted. The outcome of this evaluation demonstrated that use of these evidence-based order sets improved overall compliance with meeting stroke performance measures by more than 40 percent. The study of stroke patients also found that:
• Sixteen percent fewer patients were discharged to nursing homes
• Twenty-one percent fewer patients were discharged to an inpatient rehab facility
• Nine percent more patients were discharged home
• Thirty-six percent fewer patients were readmitted within 31 days
• Length of stay was 7.5 percent shorter
• Average direct cost per stroke case decreased by 11.4 percent
• Average indirect cost per stroke case decreased by 12.7 percent
Nurses spend less time calling physicians because orders are legible or complete, says Pamela Banchy, RN, system director, clinical information systems. In addition, departments receive orders immediately. “What used to be a four-step process that involved calling radiology or the lab, paging the physician, etc. has become a simple automated process,” she says.
Make It
Work for You
The leaders at Summa suggest the following advice for organizations
that want to redesign their work flow:
• Get bedside nurses involved in the work redesign process in the beginning.
• Standardize when possible:
• Using order sets is one way that hospitals can help prevent errors and ensure consistent, efficient care delivery.
• Simple protocols and checklists for dressing changes, wound care, IV insertion, and other nursing tasks can help reduce nurse decision time and cut documentation.
• Flow sheets that streamline documentation are used by hospitals that “chart by exception.” In such environments, the focus is on documenting exceptions to normal illness or disease progression. In other words, nurses make additional documentation when the unexpected happens.
• Realize that you can’t always build consensus. Not everyone is going to accept a change initially.
• Identify areas where there’s waste—time nurses spend waiting, looking, or delivering supplies, for example.
• Recognize that work redesign requires ongoing effort. Pre- and post-implementation evaluations can help you monitor performance.
This article originally appeared in The Business of Caring, a newsletter dedicated to helping nurse managers develop business and leadership skills. Learn more.