Project C'I'D'E'R' Clinical Interdisciplinary Documentation Education

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Using MEDITECH Clinical Enhancement as the
Impetus for Improving the Patient Care Work
Environment Project CIDR Clinical
Interdisciplinary Documentation Redesign
Salinas Valley Memorial Healthcare System
Presentation to the MEDITECH Chief Nurse
Executive Workshop November 8-9, 2007
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Presenters

• Irene Neumeister, RNSenior Vice President of
  Patient Care Services Cardiovascular
  Servicesineumeis_at_svmh.com
• Ginny Williams, RNDirector of Clinical
  Informaticsvwilliam_at_svmh.com
• Jeff Adams, RNPrincipal, The Bogart Group,
  Inc.Doctoral Student, Boston CollegeJeff.adams_at_b
  ogartgroup.com

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About SVMHS
City of Salinas in Monterey County,
CA Population - 210,000 est. Americas Salad
Bowl
Source Cejka Counseling US Census Data
Monterey Economic Report
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About SVMHS

• 269 bed acute care facility
• 2000 Employees
• Union Hospital (CNA)
• Majority of nursing staff ADN prepared
• One of 3 hospitals in the community

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About SVMHS

• Regional Heart Center
• Joint Replacement Center
• Comprehensive Cancer Care Center
• Level II NICU (Level III in process)
• Neuro-Surgical Services
• Orthopedic Services
• Pediatric Services
• Single Room Maternity Services

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About SVMHS
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History of Clinical Informatics at SVMHS

• Early MEDITECH adopter (1992)
• Like most healthcare info techfinancial systems
  implemented first
• Systems built to meet immediate needs not overall
  organizational goals
• Decentralized application management (turned into
  silos)
• Traditional PCS and IT communication challenges

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History of Clinical Informatics at SVMHSthe
Winchester Model
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JCAHO 2005 Our Learning Experience

• Knew we delivered good care
• Couldnt prove it through the documentation
• Quickly identified lack of coordination between
  policy, practice documentation
• IT willing to do what clinicians asked, we needed
  to know what to ask and help prioritizingmissing
  the VISION
• Moving forward took the position JCAHO would not
  be a looming concernwe will deliver outstanding
  carealways!

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Setting a Direction

• Assess SVMHS clinical technology environment
• Understand documentation standards
• Improve documentation, data and reporting
• Improve Information Technology structure
• Identify Clinical Information Technology
  Leadership

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Setting a Direction

• Provide coordination between policy, practice
  documentation
• Provide plans for continued maintenance,
  enhancements improvements
• Improve reliability of data/ reports
• Move towards improving the environment for staff
  and patients (Magnet)

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Organizational Commitment

• Board and Executive Team (quarterly updates)
• Executive Sponsors (weekly involvement)
• Sr. VP, Patient Care/Cardiovascular Services
• Sr. VP, Finance/Information Technology
• Administrative Sponsor (direct team involvement)
• Sr. Administrative Director, PCS
• Director, Information Technology
• Project Leadership (daily involvement)
• CIDR Coordinator
• Administrative Assistant
• External Consultant
• Specified Clinical Staff

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Project CIDR Baseline Survey Data

• Population - Patient Care Services Staff (n
  200)
• Years in position - mean 9.7
• Years at SVMHS mean 10.1
• Years working with MEDITECH 6.1
• Over 95 reported having a home computer

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Project CIDR Baseline Survey Data (quantitative)

• 72 - Confidant in my ability to document in
  MEDITECH
• 55 - MEDITECH documentation system (data) is
  accurate
• 54 - The input screens presented in a useful
  manner
• 54 - I use all of the functions available in
  MEDITECH
• 42 - I get the information I need in time
• This isnt a MEDITECH issue, it is the way weve
  built things. We know the potential, we just
  arent maximizing our use of MEDITECH!

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Project CIDR Baseline Survey Data (qualitative)

• 5 Primary Themes
• Documentation Issues (61 comments)
• Technological Support (20 comments)
• Education Issues (11 comments)
• Access Issues (8 comments)
• The Need for Change (20 comments)

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Project CIDR Teams

• Based upon an initial assessment and survey
  results, it was identified that we focus on six
  specific needs. We thus identified six select
  interdisciplinary teams.
• Auditing Testing Team
• Device Team
• Documentation Team
• Education and Communication Team
• Reporting Team
• Systems Integration

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Auditing and Testing Team

• Mission Statement
• The Auditing/Testing Team provides quality
  control measures to ensure excellence in patient
  care documentation
• Team Makeup
• 7 staff nurses 4 hrs per week
• Ad hoc members included based upon audit focus
• Results of audits routed to existing teams/
  leadership and posted on intranet
• Awareness/ Education plans developed

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Auditing and Testing Team

• Completed Audits
• Ambulation
• Status Board
• Skin Care
• Foley Care
• Post Op Incentive Spirometry
• Post Op Sequential Compression Devices
• Post Op Vital Signs
• PCA Flowsheet
• Fetal Heart Tones

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Device Team

• Mission Statement
• Evaluate and identify various categories of
  clinical bedside documentation devices improve
  the integration of point of care technology into
  clinical operations
• Set Metrics for Device Evaluation Selection
• Staff Device Evaluations Unit by Unit Assessment

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Device Team

• Device Team Makeup
• Ad hoc members included based upon device focus
  Device Team Makeup

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Device Team

• Won SINI Scholarship Award for Device Selection
  Abstract 7/07
• Patent Pending Handheld Storage Locker
• ADD PICTURE OF HANDHELD CABINET

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Documentation Team

• Mission Statement
• Create a standardized evidence based
  documentation system supporting clinical process
  that is easily accessible and retrievable for all
  disciplines enhancing communication within the
  organization and providing a comprehensive
  database for each individual patient

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Documentation Team

• Documentation Team Makeup
• Ad hoc members included based upon device focus
  Device Team Makeup

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Documentation Team

• Evaluated policies, procedures, standards of care
  and evidence based practice
• Adopted NANDA, NIC NOC
• Developed interdisciplinary content wish list
  prior to embarking on MEDITECH build.

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Documentation Team

• Clinical Documentation Content
• IP, OP, NICU, Peds, OB Admission History
• IP, OP, NICU, Peds, OB Admission Assessment
• Shift Assessment
• Care Plan(s)
• Adult and Pediatric Patient Care Screens
• Timeout Screen

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Education Communication Team

• Mission Statement
• The mission of the CIDR Education/Communication
  Team is to provide successful preparation and
  support for clinical documentation excellence for
  all patient care providers and to facilitate
  timely dissemination of current information
• Team Makeup
• 2 staff nurses and 5 clinical educators
• Ad hoc members included based upon need
  (Documentation Group)

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Education Communication Team

• CIDR Newsletter

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Education Communication Team

• Screen Savers Used for Awareness Campaign
• ADD SCREEN SAVER SHOT

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Education Communication Team

• Awareness Campaigns based on audit results
• CIDR Fest Internal Fairs
• Training and Education Plan

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Reporting Team

• Mission Statement
• The mission of the CIDR Reporting Sub-Committee
  is to optimize data collection processes for
  reporting and management needs. Understanding our
  systems output and information needs better
  defines our data collection requirements. The
  objectives are to document reporting needs.
  Identifying how SVMHS keeps abreast of changes to
  requirements, then work with related systems
  management committees to enable accurate,
  efficient data collection.

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Reporting Team

• Team Makeup
• Nursing, HIM, Quality and Risk, and IT
• Evaluate reporting needs
• Define need for data warehouse/ repository
• Slow in going, but identified need to standardize
  data and structures

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Systems Integration Team

• Mission Statement
• Assist in the CIDR redesign by assuring necessary
  movement of data between modules and/or systems
• Systems Integration Team Makeup
• 3 IT based nurses, 1 clinical educator, and 1 ED
  super user staff nurse 4 hrs per week
• Ad hoc members included based upon agenda focus

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Systems Integration Team
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Systems Integration Team

• Standardized languagenot a quick or easy sell to
  administration OR staff.
• Focus on reporting needs made this decision much
  easier.
• Currently building a lexicon for standardizing
  language used throughout the organization.
• SVMHS has adopted SNOMED, NANDA, NIC, NOC, and
  RxNorm as standardized languages

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Changes as a Result of CIDR

• Staff owns evidence based clinical practice,
  documentation technology (POC)
• Accountability, Accountability, Accountability
• More focus on Policies and Procedures
• Develop Clinical Informatics Directorship

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Changes as a Result of CIDR

• CIDR/ Clinical Informatics Newsletter
• IT Change communication improvement
• Staff IT satisfaction survey (every two years)
• Organization wide movement toward standardization
  of language (SNOMED, NANDA, NIC, NOC, RxNorm)

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Changes as a Result of CIDR

• Increased involvement in professional
  organizations
• Of the clinical staff participating in CIDR
• 1 has begun BSN program
• 2 have begun masters programs
• 1 planning to pursue PhD
• 1 has prepared application for PhD program
• 3 have prepared application for BSN program

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• Without doubt, my participation in CIDR has been
  the highlight of my nursing career at SVMH. What
  this committee has done for me personally and
  professionally is immeasurable.
• I have gained knowledge and insight about our
  documentation practices and I now recognize
  the importance of standardization, be it language
  or practice. Having different practices for the
  same procedure or process, creates confusion and
  inconsistencies.
• Perhaps the most valuable experience I have
  learned from CIDR is the engagement benefit for
  the nursing staff. By allowing frontline nurses
  to participate in this project, not only were we
  able identify problems, we were willing to take
  ownership and provide solutions.
• Lilia Meraz Gottfried, BSN, RN
• SVMHS ICU

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• Being a part of the CIDR project has truly
  changed the way that I view our hospital and the
  way I work here too.
• Once the CIDR group started working together, I
  really saw how the hospital was willing and
  wanting the staff nurses to identify any
  opportunities and find solutions and this went
  way beyond the MEDITECH system.
• The commitment by the hospital has given me the
  strength and the feeling of having some power to
  continue urging for change.
• The CIDR experience has revitalized me. Every
  week when we meet, I love to be a part of this
  very energetic groupthis has also raised the bar
  for me. This (CIDR) is a group that wants to
  demand excellence by all nursesand this has
  motivated me to make a difference in other areas
  too.
• Connie Rose RN
• SVMHS DI

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• I've had the opportunity to work closely with
  other nurses, from different units of the
  hospital,  that have the same level of care,
  concern, and dedication to nursing as I do.  The
  uniqueness of our committee has been the innate
  desire of all of us to improve nursing as a whole
  within our institution. 
• Individually, this committee and the influence
  of all of the members, has been an integral part
  of wanting to further my education.  I have
  enrolled in a Bachelor of Nursing Program and
  have just completed my 6th class.  I realize the
  importance of education and that knowledge is
  power when trying to institute change in a field
  that is constantly evolving.  I credit the CIDR
  project for my personal growth as a nurse and as
  team member of a committee that is playing a
  vital part of the  positive change that is
  happening at SVMH. 
• Debbie Ralph RN
• SVMHS Pediatrics

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• Many surprising changes have taken place in my
  attitude since I became part of the
  solutionApathy is contagious and I may have
  passed a bit of that on too.
• I always felt that because I was a passionate
  bedside nurse, I would rather be attending to the
  needs of my patients, than spending my time
  documenting. A new truth is that excellent
  bedside nursing and consciences documentation are
  not mutually exclusive but both are necessary to
  provide the best patient care.
• I am learning much about what I need to chart
  and how that impacts patient care. I have been
  able to share with my colleagues common errors in
  documentation and how it impacts information flow
  between nurses.
• It has truly been a blessing to be a member of
  CIDR. I have decided to take those extra five
  classes to finish my BSN. I also have a renewed
  sense in the professionalism of nursing and how
  even one nurse can be a catalyst for change.
• DD Rauber RN
• SVMHS Maternity Care

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Questions and Comments?

• Please dont hesitate to contact us with any
  questions, thoughts, comments.
• Wed love to hear from you.
• Irene, Ginny Jeff