Doubling Down – Obtaining
Nursing Value from an EHR
Doubling Down – Obtaining Nursing Value from an EHR
Wednesday, February 22, 2:15 p.m.
Jennifer Burrows, R.N., M.B.A.
Vice President Operations/Nurse Executive Sentara Norfolk General Hospital
Norfolk, Virginia
Laura D. Jantos, FHIMSS
Principal, ECG Management Consultants, Inc. Seattle, Washington
Learning Objectives
•
#1 - Explain how Sentara Healthcare crafted a methodology to
study and improve the time nurses spend taking care of patients
as a result of implementing an EHR
•
#2 - Recognize how to categorize nursing activities to compare
paper-based and electronic environments in a correlated manner
and to understand relevant targets and thresholds
•
#3 - Demonstrate methodologies to evaluate and improve direct
patient-care activities via an EHR
•
#4 - Define which nursing activities can and should show the
greatest enhancement after implementation of the EHR, and
which might require ongoing refinement
Agenda
1. Introductions
2. Project Rationale
3. Pre-EHR Implementation Results
4. EHR Planning Work Redesign
5. Post-EHR Impact Study
1. Planning
2. Results
6. Conclusions and Next Steps
7. Question and Answer Period.
Sentara Healthcare
•
123-year not-for-profit mission.
•
Integrated health system with full continuum of care.
•
eCare today:
– EPIC at 8 hospitals and 115 medical group locations.
– 87% CPOE.
– Realized benefits at $37.3M.
– HIMSS stage 7 award.
•
Sentara Norfolk General Hospital.
– 525-bed quaternary care facility.
– Level I trauma, burn, transplant, air ambulance.
– Magnet designated hospital.
– US News & World Report – Top 50 Cardiac Program.
Virginia
North
Carolina
eCare Vision
•
Implement an electronic medical record that
transforms how we deliver care at the bedside.
•
Design a system that improves the role of the
nurse.
•
Set up a “benefit scorecard” to ensure we drive
ourselves to realize our planned results.
eCare Implementation Planning
•
Time and motion study measuring nursing
activities was performed in 2006.
•
Set the baseline for which we would monitor the
impact of the EMR on nursing unit activities and to
identify areas we should redesign work flow.
•
Set up work teams of front line nurses.
•
Developed guiding principles to drive our decisions
and assist with conflict resolution.
Baseline Study – Background and Process
The sampling of work flow measures was performed over a 4-week
period, during which observations were conducted across all weekday
and weekend shifts.
•
Location – Observations were conducted on nine patient care departments at fiveSentara hospitals: Leigh, Norfolk General, Virginia Beach General, CarePlex, and Williamsburg Community.
•
Sampling – Fifteen staff members from five job categories (registered nurse[RN], licensed practical nurse [LPN], nursing care partner [NCP], administrative assistant [AA], and admission/discharge coordinator1) were sampled from each department.
•
Data Collection – Observations were conducted on a one-on-one basis per staffmember,2 with each session lasting 2 hours. Data was recorded manually with stopwatches and data collection sheets.
•
Data Compilation – Over 8,000 clinical and support activities were categorized andcross-correlated among observers to ensure sampling consistency. The data was then validated across all Sentara facilities to eliminate observation variation.
•
Data Analysis – Results were summarized in total, by patient care department, andBaseline Study – Background and Process
Direct Patient Care Support Activities
Category
Definition
Examples
Medical,
Technical,
Clinical
Care
Providing care or services that have
direct impact on the patient and/or the
care being delivered to the patient.
Activity Characteristics: Requires
application of functional expertise/skill.
May be a function limited by licensure.
Requires some level of critical thinking.
Assessing a patient.
Starting an IV.
Changing wound
dressing.
Running a lab test.
Shooting an X-ray.
Hotel and
Patient
Services
Providing services to maintain or
enhance the patient’s immediate physical
environment.
Activity Characteristics: Services
often found in hotels and other lodging.
Activities that directly impact patient.
Changing bed linens.
Delivering a lunch
tray.
Cleaning a patient
Indirect Patient Care Support Activities
Category
Definition
Examples of Activities
Institutional
Documentation
Documenting information
for administrative,
regulatory, and other
purposes. Does not directly
impact patient care/services
and is not contained in the
patient medical record.
• Entering patient charges.
• Accessing Pyxis machine.
• Submitting engineering work
requests.
• Classifying patient acuity.
Medical
Documentation
Documenting information in
patient medical records.
• Documenting vital signs.
• Charting diagnostic results.
• Documenting medication
administration.
Staff
Transport
Transportation of staff for
various reasons throughout
the institution.
• Walking to nursing station.
• Looking for staff or equipment.
Patient
Transport
Transportation of patients
for various reasons
throughout the institution.
• Taking a patient to X-ray.
• Taking a patient to lobby for
Indirect Patient Care Support Activities
Category
Definition
Examples of Activities
Patient
Transport
Transportation of patients for
various reasons throughout the
institution.
• Taking a patient to X-ray.
• Taking a patient to lobby for
discharge.
Scheduling
and
Coordinating
Scheduling and coordinating
various activities.
• Scheduling a patient procedure.
• Scheduling staff.
• Coordinating patient activities.
Management
and
Supervision
Activities related to the
management and supervision
of staff and resources.
• Orienting staff.
• Conducting/attending staff
meetings.
• Developing policies.
Structural
Idle Time
Time spent waiting to perform
the next activity.
• Waiting for the next admission.
• Waiting for the next call light.
• Waiting for arrival of a
Pre-EHR Study – Background and Process
NGH – 4K Registered Nurse Licensed Practical Nurse Nursing CarePartner Administrative Assistant
Admission/ Discharge Coordinator Total Weekday – Day 3 1 0 0 1 4 Weekday – Evening 2 1 1 0 0 4 Weekday – Night 1 0 0 0 0 1 Weekend – Day 1 1 1 1 0 4 Weekend – Night 1 0 1 0 0 2 Total 8 3 3 1 1 16
NGH – 5 Cardiac Registered Nurse
Licensed Practical
Nurse
Nursing Care
Partner Administrative Assistant
Admission/ Discharge Coordinator Total Weekday – Day 3 0 1 0 0 4 Weekday – Evening 2 0 1 1 0 4 Weekday – Night 1 0 1 0 0 2 Weekend – Day 1 0 0 1 0 2 Weekend – Night 2 1 0 0 0 3 Total 9 1 3 2 0 15
Pre-EHR Study – Initial Findings
1Nine observed units at Sentara hospitals. 2Figures may not be exact due to rounding.
NOTE: Observations on 5 Cardiac were conducted during the second and third weeks on the new unit.
Department NGH 4K CardiacNGH 5 Sentara
Activity Category Profile Weighted Weighted Weighted1
Medical, Technical, Clinical Care (MTC) 44.4% 38.7% 46.6% Hotel and Patient Services (HPS) 3.7% 3.2% 3.5% DIRECT PATIENT CARE SUBTOTAL2 48.1% 41.9% 50.1%
Institutional Documentation (ID) 9.2% 10.5% 11.0% Management and Supervision (M&S) 0.3% 3.1% 1.2% Medical Documentation (MD) 11.9% 14.9% 13.4%
Patient Transport (PT) 0.0% 0.8% 0.4%
Scheduling and Coordination (S&C) 8.3% 8.3% 7.8% Structural Idle Time (SIT) 12.7% 11.5% 8.4%
Staff Transport (ST) 9.4% 9.1% 7.7%
Pre-EHR Study – Initial Findings
Idle time and staff transport made up over 20% of both
department’s activity profiles.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% NGH 4K NGH 5 Cardiac Sentara
Medical, Technical, Clinical Hotel and Patient Services
Insitutional Documentation Management & Supervision
Medical Documentation Patient Transport
MTC, 44.4 % HPS, 3.7% ID, 9.2% M&S, 0.3%MD, 11.9 % PT, 0.0% S&C, 8.3% SIT, 12.7% ST, 9.4%
Department Activity Category Profile
(Weighted by Salary Cost)
Although the percentage of direct patient care was near 50% at 4,000, over 20% of staff time was spent in staff transport or idle.
MTC, 42.7 % HPS, 3.7% ID, 9.9% M&S, 0.3 % MD, 11.4 % PT, 0.0% S&C, 8.8 % SIT, 12.9 % ST, 10.2%
Department Activity Category Profile
(Unweighted)
5 Cardiac staff were spending nearly as much time on documentation
and idle time as they were in providing direct medical care.
MTC, 38.7% HPS, 3.2% ID, 10.5% M&S, 3.1% MD, 14.9% PT, 0.8% S&C, 8.3% SIT, 11.5% ST, 9.1%
Department Activity Category Profile (Weighted by Salary Cost)
MTC, 34.5 % HPS, 3.0% ID, 12.6% M&S, 2.8% MD, 12.9% PT, 0.7% S&C, 9.3% SIT, 14.9% ST, 9.3%
Department Activity Category Profile
(Unweighted)
Medical Documentation Activities
Percentage of Time
Documentation on Medical Record 57.4% Documentation of Vitals 9.2% Pre-Op Documentation 8.2% Documentation of Flowsheets 5.6% Adding EKG Strips to Flowsheet 4.1%
-- Total 100% Staff Transport Activities Percentage of Time Going to Lab 7.7% Locating Equipment 7.4% Going to Supply Room 7.1%
Categories to Consider
• Institutional Documentation • Medical Documentation • Structural Idle Time
Institutional Documentation Activities
Percentage of Time
Chart Maintenance 16.9% Accessing Medications (Pyxis) 14.9% Chart Maintenance – New Patient 12.5% Document Preparation 12.0% Printing EKG Strips 8.8%
--
Total 100%
Department Percentage of Activity Category Total Time
Medical, Technical, Clinical Care 38.7% Hotel and Patient Services 3.2% Institutional Documentation 10.5% Management and Supervision 3.1% Medical Documentation 14.9% Patient Transport 0.8% Scheduling and Coordination 8.3% Structural Idle Time 11.5% Staff Transport 9.1%
Weighted Activity Profile
Work Redesign - Project Approach
• Using LEAN 6 Sigma Methodology analyze and
redesign major work flow processes related to care
in inpatient setting.
– Defined major processes.
– Process mapping and value stream analysis.
– Change acceleration – identify cultural resistance
and develop plans for countermeasures.
– Identification of rapid improvement events that
could be implemented before EMR go-live.
Value Stream Mapping
• Current state documented.
• Activity – value added? Or NOT?
• Processes redesigned.
• Two examples:
– Order entry process.
– Shift report process.
Order Entry Process:
• 26 steps in original work flow.
• 19 steps removed.
15–60 Minutes
Work-arounds
15–30 Minutes
Shift Change Process:
• 11 steps in original work flow
• Workaround steps removed
• New streamlined process implemented
• Enhanced once EMR live
Measurement Phase
1. Nursing Overtime Reduction – OT incurred through
extended shift hand-offs.
2. Improved Nursing Recruitment – eCare efficiencies
will attract and keep nursing talent.
3. Nursing Efficiency – Nursing activities will become
more efficient through enhanced technology (streamlined
and multidisciplinary documentation, reduction in
duplication, streamlined communication between
caregivers, elimination of hand-offs, streamlining
assignments, reduction of order entry, elimination of
paper chart checks, etc.).
4. Reduction of Paper Chart Maintenance Activities –
eCare Nursing Study
•
In the spring of 2010 a second study was performed at
SNGH.
•
The purpose of this study was to:
– Measure activities performed in direct support of
patient care vs. indirect activities.
– Assess the clinical impact of implementing a Stage 7
EMR with CPOM.
– Identify opportunities and further enhancements in
areas such as: staffing mix, work
flows, communication, eCare utilization, and direct
patient care activities.
eCare Nursing Study - Methodology
•
Pre-implementation study was done on two
nursing units and consisted of 2-hour observations
of each type of staff member.
•
Post-implementation study was performed on four
nursing units and consisted of 12-hour
observations of each type of staff member.
Observations
Observation
Hours of
Documented
Activities
2006
61
122 Hours
8,000
eCare Nursing Study - Methodology
Pre-Implementation Study Objectives Post-Implementation Study Objectives
• Determine the baseline for nursing
efficiency in terms of activities performed in direct support of patient care versus indirect activities.
• Identify opportunities for clinical process enhancements in conjunction with the implementation of the Epic Systems Corporation suite of products (eCare). • Identify work flow improvement
opportunities that may be dependent on the information systems implementation so that they can be coordinated with other efforts.
• Determine efficiency, in terms of activities performed in direct support of patient care versus indirect activities, after the eCare implementation and compare that data to pre-implementation study findings.
• Identify opportunities and/or further
enhancements in areas including, but not limited to:
– Staffing mix – Work flows
– Communication – eCare utilization – Direct patient care
eCare Nursing Study - Methodology
Data Collection and Data Analysis Presentation of Findings
Project Initiation
Deliverables:
Detailed Activities List (Direct and Indirect Categorizations) Observation and Data Collection Form
Discrete Activities List
• Steering committee kickoff • Interviews • Preliminary observations • Approach and methodology finalization Deliverable: Findings and Recommenda-tions Summarize findings and opportunities for improvement: ECG Findings and
Opportunities Work Flow Assessment
Sentara
Work Flow Sampling
Methodology Clinical and
Support Activities Classification • Observations • Data analysis • Opportunity identification • Work flows • Staff utilization • Education/training • Policies/procedures
eCare Nursing Study - Methodology
Pre-Implementation Study (Study I) Post-Implementation Study (Study II) SamplingMethodology • Observation sample size was 15 total FTEs per patient care department.
• Observations were conducted across all shifts, including weekdays and weekends.
• Observation sample size was 46 total observations in four units – 4K, 6K, 5RP, and 5HH.
• Observations were conducted on weekdays, weekends, and in the evenings.
Study Interval Length
• 4 weeks (three observers). • Observations conducted
concurrently with other Sentara hospitals.
• 4 weeks (five observers). • Observations at SNGH only. Observation Locations • 4K.• 5 Cardiac.1 • 4K. • 6K. • 5RP. • 5HH.
eCare Nursing Study - Methodology
Pre-Implementation Study (Study I) Post-Implementation Study (Study II) Observation Interval Length• Observations were conducted on a one-on-one basis per staff
member.
• Each observation session lasted 2 hours.
• Observations were conducted on a one-on-one basis per staff member. • Each observation was 12 hours long.
Observation
Count • 31 total observations per unit.• Over 8,000 clinical and support activities documented.
• 46 12-hour observations in total. • Approximately 22,000 clinical and
support activities documented. Data
Collection Process
Data was gathered manually using stopwatches and data collection forms.
Data was gathered manually using stopwatches and data collection forms.
Leadership
eCare Nursing Study: Results
Activity Category Pre-ImplementationStudy1
Post-Implementation Study
Hotel and Patient Services 3.36% 5.04%
Medical, Technical, Clinical Care 38.76% 46.39%
Direct Patient Care Total 42.12% 51.42%
Institutional Documentation 11.18% 9.07%
Management and Supervision 1.51% 2.40%
Medical Documentation 12.14% 8.59%
Patient Transport 0.32% 1.24%
Scheduling and Coordination 9.07% 11.90%
Structural Idle Time 13.89% 10.08%
Staff Transport 9.77% 5.30%
eCare Nursing Study: Results
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%Hotel and Patient ServicesMedical, Technical, Clinical CareInstitutional DocumentationManagement and SupervisionMedical DocumentationPatient TransportScheduling and CoordinationStructural Idle Time Staff Transport
Pe rc e n ta g e Activity Category
Activity Category 4K 5HH1 Pre-Implementatio n Study Post-Implementatio n Study Pre-Implementatio n Study Post-Implementatio n Study
Hotel and Patient Services 3.70% 4.45% 3.00% 5.61% Medical, Technical, Clinical Care 42.70% 46.25% 34.50% 42.05%
Direct Patient Care Total 46.40% 50.71% 37.50% 47.66%
Institutional Documentation 9.90% 7.61% 12.60% 7.94% Management and Supervision 0.30% 0.21% 2.80% 4.52% Medical Documentation 11.40% 9.85% 12.90% 11.21% Patient Transport 0.00% 1.32% 0.70% 1.38% Scheduling and Coordination 8.80% 12.54% 9.30% 10.99% Structural Idle Time 12.90% 12.11% 14.90% 11.63% Staff Transport 10.20% 5.66% 9.30% 4.68%
eCare Nursing Study: Results
Pre-implementation data was not available for all units. However, a comparison of 4K and 5HH pre- and post-implementation illustrates a significant increase in direct patient care on 5HH. This may be due, in part, to the timing of the
Activity Category Percentage
Hotel and Patient Services 0.04% Institutional Documentation 4.22% Management and Supervision 0.11% Medical, Technical, Clinical Care 6.04% Medical Documentation 5.61% Scheduling and Coordination 0.60% Structural Idle Time 0.14%
Staff Transport 0.03%
Total 16.79%
Task of Total MTCPercentage
Administer Medicine 2.20% Assess Patient Record 1.91% Cardiac Monitoring 0.01% Clinical Control 0.08% Clinical Equipment 0.01% Consult Staff 0.11% Diagnostic Testing 0.14% Emotional Support 0.01% Examine Patient 0.02% I&O 0.01% Pain Management 0.01% Patient Education 0.02% Patient Preparation 0.00% Patient Room 0.08% Physical Care 0.04% Research 0.06% Shift Report 0.85%
Approximately 17% of all tasks performed were performed electronically.
As expected, electronic tasks performed most frequently were documenting the patient record
and administering medication.
eCare Nursing Study: Results
Electronic Activity
Task Percentage of Total Medical, Technical, Clinical Care Access Medicines 0.35% Chart Audit 0.35% Chart Maintenance 0.02% Check Order 0.86%
Document Activity Sheet 1.98% Document Payroll 0.08% Log Information 0.15% Order Entry 0.27% Patient Information Entry 0.02% Printing 0.07% Reporting 0.04% Task Percentage of Total Medical Document-ation Document I&O 0.05% Document Patient Record 5.01% Document Vitals 0.90% EKG Strips 0.01% Medical Orders 0.08%
eCare Nursing Study: Results
Electronic Activity
Activity Category Clin. II RN LPN NCP SecretaryUnit
Hotel and Patient Services 4.12% 3.11% 4.20% 9.55% 6.22% Medical, Technical, Clinical Care 23.34% 50.45% 46.34% 47.84% 9.19%
Direct Patient Care Total 27.46% 53.56% 50.55% 57.39% 15.40%
Institutional Documentation 9.34% 10.59% 16.23% 2.13% 14.80% Management and Supervision 16.04% 1.53% 0.11% 1.84% 0.43% Medical Documentation 2.16% 10.86% 8.43% 5.75% 6.94% Patient Transport 0.02% 0.64% 0.36% 3.17% 1.50% Scheduling and Coordination 32.07% 8.43% 10.23% 11.96% 36.90% Structural Idle Time 6.84% 9.67% 9.00% 12.23% 10.08% Staff Transport 6.07% 4.71% 5.09% 5.52% 13.94%
Indirect Patient Care Total 72.54% 46.44% 49.45% 42.61% 84.60%
NOTE: Figures may not be exact due to rounding.
While RNs, NCPs, and LPNs spend most of their time on medical, technical, clinical care, the unit secretary and Clin. II
spend most of their time on scheduling and coordination.
Observers kept a total of the following tasks during their observations.
Below are the total number of times each task was encountered by an
observer during an observation shift.
Discrete Activity Number of Times Encountered
Response to screen saver alert 0
Skin assessment 45
Interruptions during medication administration at Pyxis
machine 78
Interruptions during medication administration en route to
patient room 24
Interruptions during medication administration inside patient
room 58
Interruptions during medication administration process by
other 11
Telephone unanswered 127
Technical issue 11
