Preserving Patient Safety after the Implementation of an ......implementation. The electronic system...

Team Healthcare

1 © OPWL 2013. Do not distribute without written permission from the OPWL department at Boise State University.

Preserving Patient Safety after the Implementation of an Electronic

Health Record

Valerie Alley, Geoff Rhode, Elizabeth Martin, Angie Wolthuis

OPWL 529 Needs Assessment

Organizational Performance and Workplace Learning

Boise State University

Fall, 2013

Team Healthcare


Contents Contents ........................................................................................................................................................ 2

Executive Summary ................................................................................................................................... 4

Project Overview ................................................................................................................................... 4

Goals ..................................................................................................................................................... 4

Data Collection ...................................................................................................................................... 4

Findings ................................................................................................................................................. 4

Recommendations ................................................................................................................................ 5

Alternate Recommendation.................................................................................................................. 5

Introduction .............................................................................................................................................. 6

Client Organization ................................................................................................................................... 6

Primary Contact in the Organization .................................................................................................... 7

Team Members and their Roles ............................................................................................................ 7

Purpose of Needs Assessment Project ..................................................................................................... 8

Key Changes to the Orders Management Process during a Transfer ................................................... 8

“Exemplary” Orders Management ........................................................................................................ 9

Client Concerns and Observations ........................................................................................................ 9

Importance of Maintaining Accurate Electronic Records ..................................................................... 9

Initial Client Plan to Close Performance Gap ...................................................................................... 10

Worth of Solving the Problem ............................................................................................................ 10

Identifying the “Need” ............................................................................................................................ 11

Analyzing the Cause of the Gap .............................................................................................................. 14

Intervention Selection ............................................................................................................................. 19

Methods in Intervention Selection ..................................................................................................... 19

Organizational Constraints in Selecting Interventions ........................................................................ 20

Primary Interventions Presented ........................................................................................................ 21

Priority of selected interventions ....................................................................................................... 23

Alternative Interventions Presented................................................................................................... 23

Future Recommendations Based on Findings .................................................................................... 24

Intervention Alignment with Organizational Goals ............................................................................ 25

Conclusion ............................................................................................................................................... 26

References .............................................................................................................................................. 27

Appendix A. Mission, Vision, Values of Holy Healthcare ....................................................................... 29

Appendix B. Models ................................................................................................................................ 30

Appendix C. Data Collection.................................................................................................................... 31

Nursing Director Interviews ................................................................................................................ 31

Team Healthcare


Emergency Room Nurse Interviews .................................................................................................... 38

Clinical Informatics Department Trainer Interviews ........................................................................... 44

Clinical Informatics Department Liaison Interviews ........................................................................... 50

Observation Checklist and Data .......................................................................................................... 55

Informal Interview of Nurses Results .................................................................................................. 64

Results of Informal Poll with Nursing Directors and Clinical Educator ............................................... 65

ERIH Intervention Interviews .............................................................................................................. 66

Appendix D. Data Synthesis ................................................................................................................... 68

BEM Data Synthesis ............................................................................................................................ 68

Appendix E. Supporting Documents ....................................................................................................... 79

Training Agenda .................................................................................................................................. 79

Transfer Process Job Aid ..................................................................................................................... 87

Meeting OPWL Program’s Learning Outcomes .................................................................................. 89

../../Owner/Documents/IPT%20Fall%202013/TeamHealthcareExample_FA2013.doc#_Toc376676778

Team Healthcare


Executive Summary

Project Overview

The implementation of the Electronic Health Record (EHR) in May of 2013 changed both clinician

workflow and patient care processes at Holy Medical Center (pseudonym). The Holy Medical Center

Clinical Education Department initiated this needs assessment as a result of observed inconsistencies in

the patient transfer process, particularly when the Emergency Department transfers a patient to an

inpatient unit.

Originally, the team intended to analyze the entire transfer process. However, through observations

and feedback from data sources, the team noted improvements to the verbal handoff process following

the Clinical Skills Fair held in mid-October, at which time the Clinical Education department addressed

verbal handoffs, including the importance of chart review during the verbal handoff. Based on the

noted improvements, the team narrowed the scope of the project to focus on orders management

during transfers (admits) from the Emergency Room (ER) to inpatient units. The team specifically

examined the ER nurse’s performance related to orders management during a patient transfer from the

ER to an inpatient unit.

Goals

The goals of this needs assessment were as follows:

1. Assess opportunities for nurse performance improvement, related to orders management,

during the transfer process.

2. Develop recommendations to improve nurse performance related to orders management

during the transfer process.

Data Collection

The assessment team collected data from various sources that both directly and indirectly affect orders

management during the transfer process. The data sources were as follows:

Interviews with nurses, Nursing Directors, a Clinical Educator, Clinical Informatics Specialists,

and Clinical Informatics Liaisons

Review of related training and process documents

Observations performed as nurses completed the transfer process from the ED to inpatient units

The team used the interview data from the aforementioned sources, as well as a review of supporting

documents, to assess both individual and organizational performance.

Findings

Through the Needs Assessment process, the team found the following factors contributing to nursing

performance issues related to the orders management process during transfer:

Nurses are receiving incomplete and/or conflicting information regarding the nurse’s role in the

orders management process during transfer

The nurses’ lack the information regarding the tools available to support them on this process

and the Electronic Health Record in general

Team Healthcare


Nurses do not receive adequate feedback regarding their performance and therefore they may

not realize there is a performance issue

Nurses experience a generalized lack of motivation or buy-in to the process because of lack of

information provided to them regarding their role in the process.

Recommendations

The team makes the following recommendations, which we believe, if executed as recommended, will

help fill the performance gap:

Provide clear and accurate information regarding task responsibility and expectations: In the

nursing huddles, the charge nurses and or the Unit Director should clarify to the nurses, their

role in orders management during the transfer process. The Clinical Education department will

build a short job aid to reiterate the nurse’s role as well as guide them in how to retrieve orders

discontinued or archived.

Inform nurses of the support available from the Clinical Informatics Department: Post in the

ER and throughout the hospital, and communicate in daily huddles information on:

how to contact the Clinical Informatics Department support line; and

how the support line can be of service and provide aid.

Provide frequent feedback that is accurate, timely, and specific: Director and/or charge nurses

should complete chart audits and give both positive and constructive feedback to nurses on

their performance related to the completion of orders management. Nurses should also give

peer-to-peer feedback regarding orders management completion, which will be timelier than

Director or charge nurse feedback.

Redesign and relocate support aids: The Clinical Informatics Department and the Clinical

Education Department should collaboratively assess which job aids are necessary and relevant

to nurses, redesign them to be user-friendly, and store them in a location that is easily

accessible and user-friendly.

Alternate Recommendation

Through the assessment process, the team learned that the hospital had the option to add the

Emergency Room Inpatient Holding (ERIH) area to the EHR but elected not to at the time of

implementation. The electronic system places a patient in the holding area, in the electronic record,

while the patient waits for the ER to transfer them to an inpatient unit. Once they leave the holding

area, all of their ER orders are no longer visible on the record and the attending inpatient physician

places new orders for the patient. Another hospital in the local system uses the ERIH, and has

reported no issues with the orders management process during patient transfers from the ER to an

inpatient unit. The team recommends that the hospital investigate the feasibility of this option,

which could potentially eliminate the related performance issues.

Team Healthcare


Introduction In September 2013, as part of the Boise State University Organizational Performance and Workplace

Learning (OPWL) program, Team Healthcare formed with the intent of completing a Needs Assessment

(NA) for Holy Medical Center. Throughout the semester, the team completed a formal needs

assessment.

Client Organization Holy Medical Center started as a small community hospital in 1917 by the Sisters of Mercy —bringing

healthcare to the poor and underserved. Holy Medical Center is a not-for-profit, 152-bed acute care

hospital serving the medical needs of the community. In 2010, the healthcare system HC Regional

Medical Center purchased Holy Medical Center making a part of one of the nation’s largest Catholic

healthcare systems.

The associates of Holy Healthcare and its hospitals and medical facilities refer to its Mission, Vision, and Values to guide them as they make decisions for their organizations (see Appendix A for the organizational goals in their entirety). Mission

We serve together in Holy Health, in the spirit of the Gospel, to heal body, mind and spirit,

to improve the health of our communities

and to steward the resources entrusted to us.

Holy Medical Center

152 Bed

Hospital

2 Emergency Departments

HC Health System

4 Hospitals

Multiple medical clinics in 2 states

Core Values

Respect Social Justice Compassion Care of the Poor and

Underserved Excellence

Vision

Inspired by our Catholic faith tradition, Holy Healthcare will be distinguished by an unrelenting focus

on clinical and service outcomes as we seek to create excellence in the care experience. Holy

Healthcare will become the most trusted health partner for life.

Holy Healthcare

82 Hospitals and numerous medical clinics in 21 states

Team Healthcare


Primary Contact in the Organization

Anne Young, a clinical educator at Holy Medical Center, was the primary contact and client within the

client organization. As a clinical educator, she provides and coordinates educational opportunities for

the clinical staff including, nurses, Certified Nursing Assistants (CNAs), laboratory technicians,

respiratory therapists, and radiologic technologists. As the primary clinical educator in a small hospital,

Anne is also responsible for offering recommendations for improving nursing performance.

Team Members and their Roles

The table below summarizes the project team. Outlined in the table are the roles and responsibilities

each team member assumed throughout the duration of the project.

Table1 Project Team Members

Name and Job

Title

Department Project Role Project Responsibilities

Anne Young, MSN

Clinical Educator

Clinical

Education

Client

Project SME

Liaison between Team Healthcare and Holy Medical Center

Coordinated efforts to collect data; conducted observations

Participated in decision-making on intervention selection

Clinical Informatics Liaisons

Clinical Informatics Department

SMEs on workflow process

Provided data through interviews and chart audits

Nursing Directors Nursing Director ICU/Medical Unit

Interview Respondents

Provided data through interviews

Clinical Informatics Specialists

Clinical Informatics Department

Interview Respondents SMEs on the EHR

Provided information regarding the training on the EHR

Provided training documents

Hospital Nurses Varied Interview Respondents

Provided data through interviews

Valerie Alley

Boise State

University (BSU)

OPWL

Member of Team Healthcare

Acted as the team interview question expert by creating interview questions and observation documents

Assisted with data coding Provided connections between data and possible

solutions by completing the data synthesis

Elizabeth Martin

BSU OPWL Member of Team Healthcare

Created the data coding system Primarily responsible for coding data Researched and guided intervention selection

Geoff Rohde


Aided the team in deconstructing overly complex problems

Researched and provided connections between the NA and healthcare

Angie Wolthuis


Main point of contact between the team and the client

Coordinated efforts to keep the project on track

Acted as the primary data collector

Team Healthcare


Purpose of Needs Assessment Project This project was initiated by the clinical educator at Holy Medical Center because of her commitment in

maintaining the organization’s vision of distinguishing Holy Health Care by having “an unrelenting focus

on clinical and service outcomes as they seek to create excellence in the care experience” (Corporate

Headquarters - anonymized, 2013, para. 7.)

Holy Medical Center converted from a paper orders management system to an online Electronic Health

Record system (EHR) in May 2013. Since the implementation, the Clinical Educator has been concerned

with how nurses are adapting to the new orders management process required by the new system.

Key Changes to the Orders Management Process during a Transfer

Table 2 Former and Current Orders Management Process

Paper Process (up to April 2013)

Electronic Process (May 2013 to present)

With the paper process, when a patient transferred to

a new unit, the nurse in the receiving unit would turn

the page in the patient’s chart and start a new page of

orders. Neither the sending nurse nor the receiving

nurse was required to take action on the “old orders.”

Old orders (orders from a previous unit) were kept in

the patient’s chart and could be referred to easily by

the doctor or nurse, or any other clinical provider, by

simply turning back to the paper orders in the chart.

However, there was only one chart, which made it

impossible for multiple care providers to review the

patient’s information at one time

The new electronic system requires that the nurse from

the sending unit, either discontinue or complete the

orders. By discontinuing an order, the nurse is telling the

computer system that the order should no longer be

active by deleting it from the orders screen. The system

archives the order and marks it as “Discontinued.” By

completing an order, the nurse is telling the computer

system that the order is “complete”; that the required

action has been taken. The system also archives and

marks these orders as complete. Archived orders

disappear from the current screen, but can be found and

retrieved by users and are permanently a part of the

patient record.

Team Healthcare


“Exemplary” Orders Management

According to our client, an exemplary performer would discontinue and/or complete all Emergency

Room (ER) orders in the EHR that must not continue with the patient when the patient transfers to the

new unit. Exemplary charts would have only current and active orders on the orders screen. The

receiving unit could rely on the information in the chart and carry out the orders based on the

information on the orders screen.

Client Concerns and Observations

In August 2013, an incident occurred in the hospital and a near miss put a patient’s safety at risk. A

nurse did not discontinue an ER medication order and the order continued with the patient into the

inpatient unit, where a medication, now unsafe for the patient, was almost administered. Fortunately,

an alert nurse spotted the error and contacted the physician for clarification, where upon, the order was

discontinued in the system.

While a fatality did not occur, the client chose to investigate further in an attempt to determine where

in the process there was a breakdown. The client discovered that there was a miscommunication during

the transfer process that led to this error. She spoke with both nursing Unit Directors and nurses and

discovered that there was a confusion surrounding the transfer process, including the orders

management piece. At this point, she engaged our team to look at the performance issues related to

the transfer process.

As per the client, in order for the transfer process to be effective the nurses must complete a thorough

verbal handoff. She suggested that if the nurses referred to the patient’s electronic chart during the

verbal handoff, they would not have to go from memory and would avoid not relaying details critical to

patient care and safety.

At the outset, the team was investigating the entire transfer process, including the verbal handoff.

However, in October, the Clinical Educator used a nursing skills fair as a forum to communicate the

importance of opening the chart during a transfer in order to review patient information. Observations

completed by the Clinical Education team following the skills fair, indicated that the nurses were

opening the charts during their verbal handoffs. At that time, the team, in collaboration with the client,

determined this was no longer an issue worthy of investigation and instead decided to focus on the

orders management piece of the transfer process.

Importance of Maintaining Accurate Electronic Records

Because patients transfer successfully from one unit to another every day, Team Healthcare asked the

question: Why was investigating this performance gap important to the hospital? Using the Lean

principle of the “5 Whys” to interview the client, allowed the team to identify the value and importance

of investigating this need.

Why is it important to maintain accurate electronic records?

This decreases the chances of patient mortality and morbidity due to medical errors.

Team Healthcare


Why is it important for the hospital to avoid deaths due to medical errors?

It is the mission and vision of the Holy Medical to do no harm to patients and to seek to

create excellence in the care experience. The hospital wants to do no harm as both a

way to fulfill our mission of keeping patients safe, but also as a way to avoid costly

litigation.

What could happen if the hospital does not create an excellent care experience and harms

patients?

The Joint Commission could identify this as a violation and the Joint Commission could

put the hospital on probation or the hospital could lose its accreditation. The hospital

could also get involved in expensive litigation, which costs money, and takes resources

from our mission of caring for the poor and underserved.

Why does Holy Medical care if they lose their accreditation?

Because the members of the community would not have a full-service healthcare facility

in their immediate area and they would have to travel outside of their community for

full-service healthcare.

Why do community members need health facilities in their community?

Without emergency services in the community, sick or injured community members

might choose to delay or avoid health case, or in some instances die on the way to

finding another facility to access.

Asking these questions helped the team better understand why maintaining an accurate electronic

record is important for both the hospital and the patients they serve.

Initial Client Plan to Close Performance Gap

Originally, the client suggested that additional nursing training could address the performance gap.

With advanced EHR system training already scheduled, she felt this was a simple way to solve the issue.

However, as Dean (1993), and Mager and Pipe (1988) pointed out, worker lack of skill is not a common

cause of performance problems and rarely the only cause of performance problems. For this reason,

Team Healthcare helped the client understand that a skill deficiency is only one possible cause of the

problem and that an in-depth needs assessment would likely uncover additional causes of this problem

as well as provide evidence for such findings (Watkins, Meiers, & Visser, 2012). By pushing back on a

“training first” approach, the team was able to help the client understand there are many other causes

of, and solutions for performance gaps (ISPI, 2002).

Worth of Solving the Problem

Team Healthcare began its performance assessment by asking a very important question “Is this

problem worth solving?” Chyung (2008) suggests, “Performance becomes worthy when the value of an

Team Healthcare


accomplishment exceeds the costs needed for changing behavior in order to produce the valuable

accomplishment” (p. 109).

Because Team Healthcare is committed to adding value to the client’s organization, the team began the

needs assessment process, by asking, “What would be the cost of not doing anything about this

performance problem?” Team Healthcare recognized that if Holy Medical Center was not maintaining

accurate, timely medical records, patient safety – and maybe life itself - could be compromised. Team

Healthcare then looked closely at the costs associated with death due to hospital negligence for both

the hospital and for the survivors of the victim.

Cost of time and money associated with malpractice or wrongful death lawsuits could

have a very negative impact on the hospital. The Society of Actuaries published a study which

noted that while the average cost of inpatient medical error is about $22,000, the cost varies

widely by age of patient, type of harm (minor, major or death). The most costly errors range

from an average of over $40,000 to well over $600,000 (Shreve et. al., 2010).

Cost of mental suffering a family feels when someone passes due to the negligence of

others is immeasurable. Anger, frustration, and pain can last for years and have an effect on

both families and friends. According to Hospice Foundations of America (2013), anger,

frustration, pain can last for years and have an effect on numerous families and friends, thus

lowering quality of life for survivors.

Because of the cost of not doing anything about this performance problem was so great, Team

Healthcare identified this as a worthy project. The team believed that the cost of any recommended

intervention would be less than a potential lawsuit and/or the pain and suffering inflicted on survivors of

the victim.

Identifying the “Need” Watkins et al. (2012) note that the first step in a needs assessment is to identify the gap between

desired and current results. Below are the methodical steps Team Healthcare used in determining the

client’s needs.

Step #1 Established relationships and boundaries with client

In support of the ISPI code of ethics (2002) Team Healthcare set clear expectations with the client about

the systematic process we planned to follow, before proceeding with the needs assessment. To build

trust with the client, and to conduct our assessment within the bounds of the ethical standards set forth

by ISPI, the team did the following:

Obtained official written permission from our client to conduct our study

Agreed to keep conceal the identity of the organization and interviewees

Agreed to keep the client informed of key findings before moving to each process

Established a professional relationship with all parties involved when collecting data

Team Healthcare


Step #2 Used a systematic approach in identifying the need

Team Healthcare began the investigation of identifying the performance need by using Harless’s (1987)

13 questions as a way to determine if there was a performance problem. It was the team’s desire, as

suggested by Harless, not to “waste” (p. 7) the hospital’s money investigating things that are not

problems. To begin our investigation, the team set out to answer Harless’s first three questions:

1. Do we have a problem?

2. Do we have a performance problem?

3. How will we know if the problem is solved?

Step #3 Collected data to establish the need

To investigate the existence of a gap in performance, Team Healthcare purposely looked at various

sources of information to triangulate our findings. According to Miles and Huberman (1984)

“Triangulation increases our confidence about a finding by helping us determine if other sources echo it”

(as cited in Rossett, 2009, p. 3).

The team used several data sources, as well as several methodologies by which to collect and triangulate

data to verify that there was a performance gap. Table 3 outlines the data the methodologies and data

sources the team used to assess the gap and verify the need for a complete NA. The impact of the data

is provided following table 3.

Table 3 Data Collection Methods

Data Collection Methods

5 Individual Interviews

Physician Liaison- Clinical Informatics Department

Orderset Coordinator- Clinical Informatics Department

Clinical Liaison- Clinical Informatics Department

Clinical Educator- Clinical Education Department

Charge Nurse- Emergency Room

Audit of 14 files Due to concerns of violating patient confidentiality, Team Healthcare was unable to review charts. Hospital personnel audited the charts.

Step #4 Analyzed data and summarize key findings

Evidence from both patient chart audits and interviews with key personnel, prove there is a gap

between the required and current state of discontinuing the electronic orders.

As outlined in table 3, of the 14 charts audited, the auditors classified approximately 70% as not up to

hospital standards. An interview with the Clinical Educator indicated that one nearly fatal mistake

occurred, due to improper orders management, but fortunately, competent staff diverted a possible

fatality. Furthermore, in an informal interview with Medical Unit and Intensive Care Unit (ICU) nurses,

the team asked nurses to rate, on a scale of 1 to 5 (1 being not well at all and 5 being really well), how

well the orders are cleaned up in a chart when they receive a transfer patient. The nurses answered

Team Healthcare


with an average of 2.17, which further points to an issue with orders management during transfer. The

client indicated that average of 4 would be expected and 5 would be optimal.

Table 4 Overview of Collected Data

Data Collection

Method

Reviewed by or

Interviewee

Data

Audit 1 Physician Liaison 3 out 4 files from the Emergency Department were not cleaned

up as they should have been

Audit 2 Orderset Coordinator 3 out 5 files were clearly not updated properly before the

transfer

Audit 3 Charge Nurse 4 out of 5 charts are not cleaned up when charge nurse puts in

admit orders

Interview Clinical Liaison Approximately 70% of charts audited are not updated properly

Interview Clinical Educator “The only evidence I have is the comments I hear from the 2

directors of the receiving floor that the orders are not cleaned

up” “We have had 1 incident where there was some confusion

with which orders where current and were not which almost

caused a deadly situation.”

Interviews (informal) 3 Medical Unit nurses

3 ICU nurses

On average, gave the following question a 2.17: On a scale of 1 to 5, 1 being not well at all and 5 being really well, how well do the nurses perform the transfer handoff process?

Step #5 Answered Harless’s first 3 questions

1. Do we have a problem?

Yes, nurses are not properly completing the orders management process in the

Electronic Health Record before transferring a patient to another unit.

2. Do we have a performance problem?

The nurses sometimes complete the orders management process, which indicates this

may not be a knowledge or skills problem, but instead a performance problem.

3. How will we know if the problem is solved?

We will know the problem is solved, when nurses are completing the orders

management process in the Electronic Health Record before transferring a patient from

the ER to an inpatient unit, more frequently than 30 % of the time (the estimated rate of

compliance), eventually reaching 100% compliance.

Step #6 Defined the need

Team Healthcare defined the need as:

The ER must increase the frequency at which the nurses complete the orders

management process in the Electronic Health Record before transferring a patient to an

inpatient unit.

Team Healthcare


The client agreed this was the appropriate need. When the team looked at the problem, the nurses

were discontinuing orders periodically, so the team determined they had skills and knowledge to do so.

However, something was causing them not to complete the process on a consistent basis. Based on this

assessment, the client gave Team Healthcare permission to investigate the causes of this performance

gap.

Graphic 1 The Gap

Analyzing the Cause of the Gap Watkins et al. (2012) notes that the second step in a needs assessment is to collect information

regarding the causal factors or root causes that could be causing the gap. Below are the methodical

steps Team Healthcare used in determining potential causes.

Step #1 Selected a systematic approach to determining the causes

After reviewing the need to increase the frequency at which the nurses complete the orders

management process in the Electronic Health Record before transferring a patient from the ER to an

inpatient unit, Team Healthcare identified this is an operational deficiency. As Watkins et al. (2012)

points out, the operational level includes “carrying out tasks to produce results” (p. 40). This

operational task or completing the orders takes place between nurses when a patient is transferred

from the Emergency Room to an inpatient unit.

Team Healthcare chose to use the Behavioral Engineering Model (BEM) and pieces of the Synchronized

Analysis Model (SAM) to guide us throughout the NA because they align well to smaller operational level

organizational needs. The SAM utilizes pieces of the Behavioral Engineering Model (BEM), a model that

focuses on the worker (see Appendix B for the SAM and BEM models). “At this level the SAM is identical

to the BEM’s original repertoire of personal behaviors. It includes knowledge, skills, capacity, and

motives” (Marker, 2007, p. 29). Because we suspected causes of the gap stemmed from factors in the

environment, or in the individuals carrying out the tasks in the organization, Team Healthcare believed

the BEM was the most appropriate model. The team also wanted to investigate the possibility of

internal organization communication issues, which is why the team also consulted the SAM.

Required State

Current State

Nurses complete the orders

management process (discontinuing and/or completing orders) in the Electronic Health Record, before they transfer a

patient to a new unit,

approximately 30% of the time.

Nurses do not complete the orders management process

at least 70% of the time.

Desired State

Nurses complete the orders

management process (discontinuing and/or completing orders) in the Electronic Health Record, before they transfer a

patient to a new unit, approximately 100% of the time.

The Gap

Team Healthcare


The team found using the BEM and SAM also helped us “to observe behavior in an orderly fashion and

ask the ‘obvious’ (the ones we so often forget to ask) toward the single end of improving human

competence” (Gilbert, 2007, p. 95).

Step #2 Collected data to establish the causes

As outlined in Table 5, a large portion of the data collected was qualitative data, obtained by one on one

interviews. Following the suggestions of Schensul and LeCompte (1999), the interviewer captured the

responses to the interview questions, verbatim. A third party conducted onsite observations of the

process, using a checklist provided by Team Healthcare. Due to concerns for patient confidentiality, the

team was unable to audit patient files, but did have onsite personnel conduct them and provide the

team with the results. Finally, the team reviewed training agendas provided by the Clinical Informatics

Department, the department responsible for training during the implementation and for ongoing

support for the EHR.

Table 5 Data Collection Methods Data Collection Methods

17 Individual Interviews

Unit Nursing Directors x 2 – Medical Unit and ICU

Physician Liaison- CID

Orderset Coordinator- CID

Clinical Liaison- CID

Clinical Educator- Clinical Education Department

Charge Nurse- ER

Staff Nurses x 2 – ER

Staff Nurses x 3 – Medical Unit

Staff Nurses x 3 - ICU

Clinical Informatics Specialists x 2 - CID

14 File Audits Due to concerns of violating HIPAA regulations, Team Healthcare was unable to review the charts personally. Hospital personnel audited the charts and relayed the information to Team Healthcare.

4 Observations

The team created an observation form, which the client and her colleague used to conduct observations of nurses completing the transfer process.

Review of Support Materials

The team reviewed training agendas used for implementation training to determine if the training covered orders management during transfer.

Step #3 Identified major and minor data trends

After collecting the data, the team used a deductive approach to coding the data (as outlined in table 6).

Using the advice from LeCompte and Schensul (1999), the team coded and organized the data into

categories related to the BEM/SAM framework. The team then color coded the data and then

quantified the data by counting each piece of data to identify trends.

Team Healthcare


Table 6 Team Health Care Code Book

Step #4 Synthesized the data to find “evidence” of major trends Table 7 Overview of Major Data Trends (see Appendix D for complete synthesis)

Information Instrumentation Motivation

Data Resources Incentives

Environmental

Major Trends

The team found:

Conflicting information concerning task responsibility in 17 pieces of evidence extracted from 10 interviews

Lack of adequate feedback in 10 pieces of evidence extracted from 9 interviews

Lack of information about support in 7 pieces of evidence extracted from 7 interviews; this is also an information problem

Major Trends The team found: Lack of time to complete the

EHR in 7 pieces of evidence extracted from 7 interviews

Lack of adequate job aids in 6 pieces of evidence extracted from 6 interviews

Knowledge Capacity Motives*

Internal Major Trends

The team found:

A lack of confidence to manage the orders due to inadequate training in 5 pieces of evidence extracted from 4 interviews

Major Trends The team found: Inadequate motivation by nurses

to manage the orders in 8 pieces of evidence extracted from 7 interviews

Inadequate motivation to work with CID support team in 10 pieces of evidence from 3 sources

* These trends are a diffusion effect stemming from a lack of information

KNWLDG

Team Healthcare


Step #5 Conceptualized the causes through graphic representation

Graphic 2 Environmental and Internal Causes of Gap

Conflicting information

concerning task responsibility

Lack of information about

support tools

Insufficient/confusing resources

Lack of feedback about current

performance

Lack of adequate confidence

(skill) to clean up orders

Need (Gap)

Nurses do not

complete the orders management process

at least 70% of the

time.

Environmental

Causes 65%

Internal Causes

35%

HMC transfer process and the process of HC Regional

Medical Center do not align

Lack of time to complete the

new orders management

process

Inadequate motivation by

nurses to clean up the

orders and accept new ideas

Diffusion effect

Lack of

Information

Lack of trust

Team Healthcare


Step #6 Summarized major data trends for performance gap

As represented in Graphic 1, the preponderance of evidence pointed to environmental issues as the

most influential leverage points for the performance gap. For example, the Holy Medical Center

transfer process does not align with the process of HC Regional Medical Center, the largest hospital in

the local health system, and the first site to implement the EHR. The client site opted not to adopt the

process of HC Regional Medical Center, but their reasoning was unclear and the team was unable to

collect the necessary data to understand their decision.

The following are major trends noted during the data synthesis:

1. Conflicting information concerning task responsibility

Trainers taught the process to the nurses as if the doctors “owned” the process, but

nurses are the ones actually doing this process in real time. There is a lot of hesitation by

the nurses to complete the orders management process due to the confusion of roles

and responsibilities between the doctors and the nurses.

2. Lack of information about support tools

Staff does not know who to go to regarding support and/or clarification on the orders

management process, or for general process questions regarding the EHR.

3. Lack of adequate feedback

The nurses do not receive adequate feedback regarding their performance from

Directors, the Clinical Informatics Liaisons, and/or peers in receiving departments.

4. Insufficient/confusing resources

The staff believes job aids are either too long, too complicated, and/or have forgotten

where to find them.

While most of the issues stem from a lack of information and feedback, there appears also to be a

diffusion effect that leads to motivational issues. Because the nurses do not understand the

expectations of them in the orders management process and they are not receiving feedback regarding

the process, their comments suggest they are somehow not motivated to complete the process.

However, it is apparent that nurses’ motivation is not the cause of the problem, rather a symptom that

can likely be addressed by fixing problems of the sort noted above.

Step #7 Summarized strength of organization

During the investigation of causes of the gap, Team Healthcare identified key areas of strength for the organization.

1. Nurses’ dedication and care for patients

Evidence from interviews with nurses and Nursing Directors indicate a compassion and

commitment to the patients they serve. Although they may not understand the “why”

behind orders management and what it brings to them personally, they are dedicated to

trying to do what they need to, to care for their patients.

Team Healthcare


2. Verbal pass down between nurses

Observations of 4 nurses, showed all 4 nurses doing a verbal pass down and using the

Electronics Health Record while conversing. Although Team Healthcare originally

believed the verbal pass down process was an area of need for the hospital, there was

an improvement to this piece of the transfer process following their Skills Fair held in

October.

3. Computer access to complete orders

Observation of 4 nurses showed all nurses being able to access a computer to complete

the orders management process. Although the computers were not in the patient

rooms, nurses were able to find a computer in a nearby location.

Intervention Selection Watkins et al. (2012), notes that the third step in a needs assessment is to identify multiple solutions for

achieving the desired results. Team Healthcare presented our interventions and partnered with the

client to select the appropriate interventions that would eliminate the gap and meet the organization’s

constraints of limited budget and time.

The team systematically selected intervention options by aligning the underlying causes, as identified

through the analysis, with those solutions best equipped to address the issues while remaining within

the limitations of the client organization. There were two central steps in this process:

1. Selecting a range of interventions able to close the gaps according to the data

2. Narrowing the intervention list based on organizational restrictions

Methods in Intervention Selection

As per Van Tiem, Moseley, and Dessinger (2001), step one consisted of individual and team reviews of

the findings followed by proposals of possible solutions over the course of multiple brainstorming

sessions. Each member contributed approximately three solutions with accompanying rationale. The

team then used multi-voting to generate seven possible solutions viewed as to be appropriate in

combating the performance issue. This step also produced a working list of potential constraints to

discuss with the client.

As discussed previously, the analysis findings indicate impacts on performance in the categories of:

information, resources, and motivation, with the majority of the findings suggesting deficits in

information as the primary cause. Closely related was the lack of effective feedback on this task as well

as increased time to complete the task, caused by the requirement to complete the orders management

process in the EHR. Apparent motivational issues seem to stem from a hesitation by the nurses to clear

the old orders. Data from nurse interviews show that some believe that the orders management

process is not a nurse responsibility, but rather that of the doctor while others are unsure of their role.

While this may be, in part, contributing to the performance gap, the team believes that it is not the

primary cause but rather an effect of conflicting information about task responsibility. Consequently,

we believe that with clarified information and frequent, efficient feedback motivation may increase.

Team Healthcare


It was evident that a lack of skill or knowledge concerning how to perform the task was not the likely

cause as the nurses had previously managed orders prior to the implementation of the EHR and had

received mandatory training. Because of this, the team eliminated the training-based interventions

from the list of potential interventions.

From these findings, Team Healthcare recommended a course of action that would first and foremost

clarify and inform the nurses of their role and expectations in this task and secondly, improve

performance feedback. Without this information, the nurses cannot perform as expected as they do not

know:

1. that they are expected to complete this task, and

2. how this task it to be performed (expectations).

Furthermore, providing effective feedback and gauging performance on a task unknown to the

performance as required would be a challenge and potentially damaging to the nurse’s motivation if

they feel that they are being evaluated unfairly. Additionally, the team discovered that there is

currently no method in place to collect data on performance of this task. Because performance data is

crucial to feedback as well as a host of other initiatives, we also suggested the hospital consider

implementing a process to gathering this type of information.

Though the team did find evidence of a motivational issue, we felt that because motivation is an internal

construct, thus difficult to gauge, focusing on environmental solutions would be the best course of

action to address what we believe to be the root cause. Additionally as shown in many studies

conducted by Rothwell (2005), environmental factors constitute the majority of causes behind

performance problems. As such, interventions addressing environmental causes tend to be highly

effective while also cost-effective when compared to those targeted toward addressing internal factors.

Organizational Constraints in Selecting Interventions

This step involved Team Healthcare contacting the client in a series of discussions about organizational

constraints to consider while reviewing the options. The primary constraints identified by the client are

as follows:

A limited budget

Limited time, possible resistance

The necessary for ease of implementation

Team Healthcare and the client identified five of the original seven, based on these constraints, as

solutions well-suited to address the issues. Tables 8 and 9 found on pages 21 - 23 outline solutions

approved by the client contact for further consideration by additional stakeholders. Following the

tables, are the alternative interventions, those considered but not selected, as well as thoughts on

future interventions.

Team Healthcare


Primary Interventions Presented

Table 8

Interventions Addressing BEM Information Factor

BEM Category: INFORMATION

Issue Evidence Recommended Solution Benefits Disadvantages Client’s Comments

Conflicting

information

concerning

task

responsibility

Trainers told nurses,

during training, that

orders management

during transfer is the

doctor’s responsibility.

However, the Nursing

Directors and Clinical

Informatics Liaisons

believe it is the

nursing staff’s

responsibility.

1. Provide clear and accurate information

regarding task responsibility

Managers will notify nurses during a team

huddle that they are expected to complete

and/or discontinue orders prior to

transferring a patient. The Clinical Education

Department will provide a brief (less one

page) job aid outlining how to clear the

order and how to retrieve old orders if a

mistake is made. The manager should allot

time for a Q and A session.

2. Provide clear communication of

performance expectations regarding

task

Management to provide clear performance

expectations to the nurses concerning the

orders management process during transfer.

The method of communication is at the

discretion of the manager and should align

with current communication processes.

Low cost

Simple implementation

Likely to be accepted by nursing staff

Time to create job aid

The meeting or huddle may run longer than expected

“This solution makes sense and we will be

able to easily communicate this at the daily

huddle. I can make a quick job aid reminding

the nurses of their role along with how to

retrieve ‘deleted’ orders. I will make sure

the charge nurses do this immediately

(communicate to the nurses that it is their

responsibility to complete orders

management and it is within their scope of

practice to do so). I will also create a short,

concise job aid to put at the workstations for

easy retrieval.”

Team Healthcare


Perception of

a lack of

support from

the Clinical

Informatics

support team

Support tools are

available to the nurses

however, there has

been a lack of

communication about

them.

The majority of nurses

reported not knowing

whom to contact for

support.

Inform nurses of the help available

from the Clinical Informatics

Department

Provide all necessary information regarding

how to contact the Clinical Informatics

support line. This might be done a variety of

ways including:

Nursing “huddles”

Memos

Post informational flyers in the unit and break rooms

Official staff meetings

Low cost

Simple implementation

Likely little to no resistance

May need some nursing resources to help with the project

“This solution is doable. We will post the

number of the CID help line all over the

hospital – including at the workstations.”

BEM Category: RESOURCES

Issue

Evidence Recommended Solution Benefits Disadvantages Client Comments

Inefficient/confusing

resources

Nurses state

that the job

aids are

difficult to use

and difficult to

find.

Job aid redesign and relocation

Consult with members of the nursing staff and

Clinical Informatics Department to create new or

modify existing aids so that they are more user-

friendly and in an accessible location.

A redesigned job aid may be more effective

Easier to use

Easier to access

The redesign process may take a large amount of time to complete

“We would have to work with

the Clinical Informatics

Department on this, but I think

this is something we should look

at anyway. I think we will assess

which job aids the nurses need

and create a quick reference

guide that they can have in the

units and at the workstations.

Table 9

Interventions Addressing BEM Resources Factor

Team Healthcare


Priority of selected interventions

Following the selection, the team and client contact prioritized the solutions in such a way to promote the provision of

needed information quickly while maintaining or improving motivation. As shown below, we are suggesting that the

interventions focused on providing clear and accurate task information and expectations come before the provision of

feedback. . We believe that providing feedback during the same timeframe as this information is being communicated

may negatively impact motivation if nurses feel they are being evaluated unfairly.

1. Provision of clear and accurate information regarding task responsibility and expectations

2. Provision of feedback

3. Job Aid Redesign and Relocation

Alternative Interventions Presented

Adoption of the Emergency Room Inpatient Holding (ERIH) Area

One intervention considered ideal by the team is the adoption of the Emergency Room Inpatient Holding area,

or ERIH. This holding area is an added component to the EHR in which all orders move from the active orders

page to an archive in a patient’s file, upon unit transfer. As a result, the patient enters the new unit with a

“clean slate”. In theory, the ERIH function effectively reduces the risk to patient safety, thereby eliminating the

risk of financial obligations (lawsuits and/or settlements) related to human errors in the orders management

process during transfer process. Currently, the ERIH has been effective in the ER unit of the sister location, as

noted by a number of Holy Medical Center staff members including a Clinical informatics Specialist, a Clinical

Educator, and a Clinical Informatics Liaison. They all stated that ERIH has created a smoother, faster transfer

process that to them appears to result in less confusion about current and expired orders.

Though Holy Medical Center has the same EHR system, they chose not to adopt the ERIH function because at

the time of the implementation, the hospital believed their process to be effective, thus, not viewing the added

function as a necessary cost. However, this may not be the case as audits and nurse and director interviews

indicated an increased amount of time spent using performing this task as well as several errors or instances of

nonperformance. These issues have the potential to be incredibly costly and damaging to the organization.

Because of the level of risk associated with the current problem as well as some evidence suggesting the

effectiveness of the ERIH, the team believes that the adoption of this function may provide an optimal solution

as it essentially eliminates the opportunity for error by bypassing the human component in this piece of the

orders management process. However, due to time and constraints from the client and the limitation of the

team’s 15-week school schedule, Team Healthcare was unable to gain enough data to fully support this

recommendation.

Status: Under consideration

Rationale: Acknowledging the limitations of our data, we are not recommending it as a solution, but

rather recommending that the client look for more data to support it as the optimum solution, and

subsequently evaluate the feasibility for their site.

Performance management

The Clinical Informatics Department would determine the cost of creating a computer-generated report that

tracks progress towards 100% ER compliance with orders management when moving / admitting a patient from

the ER to an inpatient unit. The purpose behind suggesting this intervention was to provide a way for the

hospital to gain definitive information about task performance, which they could use in a host of applications.

Team Healthcare


Some of the uses might include feedback for staffing and compensation decisions, or larger scale decisions such

as training programs or process design.

Status: Not chosen by client

Rationale from Client: “Since the EHR is a corporate tool that supports 21 hospitals and an organization

with 85,000 employees, it is difficult to get any changes made. I have made note of this and will suggest

it, but it is not a solution that we could implement immediately and may never come to fruition.”

Adapt performance appraisal to include orders management during transfer

The team believed by adding orders management the performance appraisal, nurses would clearly see it as their

responsibility and would work to improve their performance.

Status: Not chosen by client

Rationale from Client: “This may be feasible in the future, but at this point, I think it makes more sense

to see if we can improve performance in other ways. We have an annual performance appraisal that

happens in July – the nursing goals have already been set for this year. If there has not been

improvement by this summer, I will recommend we look at this as an option.”

Future Recommendations Based on Findings

Recommended for future implementation are the following interventions:

1. Training modification, to include:

Update to information regarding orders management task responsibility

Nurses were misinformed about their role in the task during the mandatory EHR training conducted by the

Clinical Informatics Department. The team suggests updating the training program so that this task is clearly

presented as a nurse responsibility and is appropriately discussed so that the staff feels confident in

managing the orders prior to transfer.

2. Computer skills training

Some nurses reported having difficulty with the EHR system due to a lack of computer skills. The team believes

that offering optional computer skills training, to those interested, may increase the confidence of these nurses

in their ability to use the EHR.

3. More hands-on practice to increase confidence

A number of nurses reported the desire for more hands-on practice. Adjusting the training sessions to

include hands-on activities may increase the nurses’ confidence in their ability to use the system.

Team Healthcare


Intervention Alignment with Organizational Goals

Once the team and the client agreed on suitable interventions to fill the performance gap, the team reviewed the

selected interventions to ensure they were in alignment with Holy Medical Center’s organizational goals. Table 10

outlines at which level (Watkins et.al, 2012) the intervention will impact the organization and how the intervention is in

alignment with the goals of the organization.

Table 10 Interventional Alignment with Organizational Goals

Intervention Level Link to Organizational Goal(s)

Provide clear and accurate information regarding task responsibility

Operational Goals:

Implement processes that are Lean

Provide excellence in the care experience In the past three years, there has been an organizational focus on Lean processes. The organization looks at all processes and asks, “Is the way we are doing this a ‘value add’ (adding value)?” The Lean philosophy challenges the associates in the organization to look at current processes and find ways of doing them more efficiently and effectively. Currently, the ER nurses are not completing the process or only partially completing the orders management process. This puts a burden on the receiving unit nurses – they spend productive time attempting to decipher the orders. Not only is this inefficient, it could compromise patient safety. By clarifying to the ER nurses what their responsibilities are related to the orders management process during transfer, they will more effectively complete the process, thereby, saving time for the receiving nurses. This helps the hospital meet their goal of being a “Lean” organization. The nurses completing the process correctly will mitigate confusion for the receiving nurses. They will no longer have to ‘guess’ which orders are current. An accurate and complete chart represents a safer environment for patients, which helps the hospital meet their goal of providing “excellence in the care experience” (see Appendix A).

Provide clear communication of performance expectations regarding task

Operational Goal:

Earn a 4 on the Joint Commission mock survey

A hospital goal for the year 2014 is to receive a score of 4 on their Joint Commission mock survey. A 4 indicates that the mock surveyors find 10 or fewer violations and/or opportunities for improvement. The Joint Commission requires that the nurses follow a standardized process during a handoff (Friesen, White, & Byers, 2008). By communicating to the nurses the expectations for performance related to the orders management process during transfer, nursing performance should improve both in the orders management process and the overall transfer process. If nurses improve their performance, the hospital will avoid a violation during the mock survey, which will help the hospital achieve their goal of a 4.

Team Healthcare


Inform nurses of the help available from the Clinical Informatics Department

Tactical Goal:

Work together as a unified healthcare system to become the “most trusted healthcare partner for life” (see Appendix A).

Through the interview data gathered, the team was able to deduce that there is a lack of

communication between the main hospital in the health system and the ancillary

hospitals. Because this organizational communication issue was outside the scope of our

project (due to time constraints), the team did not make efforts to triangulate the data to

validate this. However, the team believes that one way to improve this organizational

communication problem is to inform the nurses that there is a Clinical Informatics

Department that is available to offer support. It was clear that the nurses did not know

the department is there to offer support regarding both technical and process questions.

The associates in the CID are experts and by offering their expertise to the nurses at Holy

Medical Center, they will bridge that communication/ relationship gap. As the two

hospitals work together more collaboratively, they will become more unified in their care.

This unification will allow them to provide excellent care across the entire system, and

patients will be able to trust that they will receive great care regardless of the facility in

which they receive care. Over time, patients will begin to trust the system and the care

they receive there and will “partner” with the system as a patient – for life.

Job aid redesign and relocation

Operational Goal:

“We are impatient to do better and hold ourselves accountable for continuous

improvement in the services we offer” (see Appendix A).

The job aids designed by the Clinical Informatics Department describe both the

functionality of the system and the processes that align with the hospital’s policies. While

the aids are complete and accurate, according to the data gathered by the team (see

Appendix C for complete data) they are difficult to locate and cumbersome to use. By

assessing which job aids are most relevant at the time, re-working them to make them

more user-friendly, and relocating them so they are easily accessible, the CID and the

Clinical Education department are contributing towards the hospital’s mission to

continuously improve in order to enhance the services offered.

Conclusion While the performance gap exists and the team believes the recommended interventions will fill that specific gap, the

team noted that orders management in general (not just at transfer) seems to be an area of confusion for nurses. The

team suggests that the organization align itself in its processes and communication to ensure that nurses understand

their roles in all EHR-related tasks and processes.

Team Healthcare


References

Anonymized. (2013). Mission, values, vision. Retrieved October 17, 2013 anonymized.

Chyung, S. Y. (2008). Foundations of instructional and performance technology. Amherst, MA: HRD

Press.

Friesen MA, White SV, Byers JF. Handoffs: Implications for Nurses. In: Hughes RG, editor. Patient Safety

and Quality: An Evidence-Based Handbook for Nurses.Rockville (MD): Agency for Healthcare

Research and Quality (US); 2008 Apr.Chapter 34.PubMed PMID: 21328750. Retrieved from:

http://www.ncbi.nlm.nih.gov/pubmed/21328750Gilbert, T. (2007). The behavior engineering

model. In Human competence: Engineering worthy performance (tribute edition) (pp. 73-107).

San Francisco: Pfeiffer.

Harless, J. H. (1978). An analysis of front-end analysis. Performance + Instruction, 26(2), pp 7-9.

Hospice Foundations of America. (2013). An Introduction to grieving. Retrieved from

http://www.hospicefoundation.org/pages/page.asp?page_id=171387

ISPI. (2002). Code of Ethics. Retrieved from http://www.ispi.org/pl/About/Code-of-Ethics.pdf

LeCompte, M., & Schensul, J. (1999). Analysis from the top down. In Analyzing & interpreting

ethnographic data, 5, pp. 45-66. Walnut Creek, CA: AltaMira Press.

Mager, R., & Pipe, P. (1997). Analyzing Performance Problems (3rd ed.). Atlanta, GA: Center for

Effective Performance.

Marker, A. (2007). Synchronized analysis model (SAM): Linking Gilbert's behavioral engineering model

with environmental analysis model. Performance Improvement, 46(1), 26-32.

Miles, M., & Huberman, A.M. (1984). Qualitative data analysis. Thousand Oaks, CA: Sage.

Rossett, A. (2009). First things fast: A handbook for performance analysis. San Francisco, CA: Pfeiffer.

Rothewell, W. J. (2005). Beyond training and development: The groundbreaking classic on human

performance enhancement (2nd ed.). Saranac Lake, NY: AMACOM Books.

http://www.ncbi.nlm.nih.gov/pubmed/21328750

http://www.hospicefoundation.org/pages/page.asp?page_id=171387

http://www.ispi.org/pl/About/Code-of-Ethics.pdf

Team Healthcare


Schensul, J., & LeCompte, M. (2013). Essential ethnographic methods: A mixed methods approach (2nd

ed.). Lanham, MD: AltaMira Press.

Shreve, J., Van Den Bos, J., Gray, T., Halford, M., Rustagi, K., & Ziemkiewicz, E. (2010). The economic

measurement of medical errors. Retrieved from:

http://www.soa.org/Files/Research/Projects/research-econ-measurement.pdf.

United States Environment Protection Agency. (2011). Lean thinking and methods. Retrieved from:

http://www.epa.gov/lean/environment/methods/index.htm

Van Tiem, D. M., Moseley, J. L., & Dessinger, J. C. (2001). Performance improvement interventions:

Enhancing people processes and organizations through performance technology. Silver Spring,

MD: International Society for Performance Improvement

Watkins, R., West Meiers, M., & Visser, Y. (2012). A Guide to assessing needs: Essential tools for

collecting information, making decisions and achieving development results. Retrieved from

http://www.needsassessment.org

.

http://www.epa.gov/lean/environment/methods/index.htm

Team Healthcare


Appendix A. Mission, Vision, Values of Holy Healthcare Mission We serve together in Holy Healthcare, in the spirit of the Gospel, to heal body, mind and spirit, to improve the health of our communities and to steward the resources entrusted to us.

Core Values

Respect - We value and esteem every human person because each and every one is created by God, in the image of God. Everyone, regardless of title or position, income, education or status, race, religion or ethnicity has a dignity that is sacred. We treasure and hold human life sacred from its simplest beginnings until its end. (Gen. 1:26; Luke 9:47-48; John 10:10)

Social Justice - In this age of globalization and instant communication, we more quickly recognize our common humanity. We recognize as well the great gaps in economy, health, education and development among the peoples of this earth. Social justice commits us to the common good so that all may have their basic needs met. We recognize health and access to healthcare as a basic human right and seek to provide and advocate for it. (Wisdom 9:2f; Isaiah 32:16-18.)

Compassion - People come to us when they are in need and in distress. In the spirit of Jesus, we recognize their need and seek to respond to it. We reach out to them in their pain and suffering and care for them in body, mind and spirit. The ability to feel and to respond to the suffering of others is an essential value in our ministry of healthcare, no matter where we serve. We recognize also that those we cannot cure we can still love, care for and be with in their suffering. (Mark 1:40f; Mark 10:51; Luke 4:40 Luke 10:30-37; Romans 12:15; I Cor. 13:4-7)

Care of the Poor and Underserved - God hears the cry of the poor and so, with respect and compassion, we seek out the poor and underserved as a special focus of our healthcare ministry. It is those without resources of their own who need us most. We seek to care not only for their immediate needs but also to change the structures that keep them in unhealthy environments and inhumane conditions. Through our ministry of health care and our persistent advocacy, we seek to serve the poor and underserved of our communities. We too hear the cry of the poor and underserved. (Acts 4:32-35; James 2:15)

Excellence - The scriptures look to the day when there will be a new heaven and a new earth, when creation will be made perfect. Our vision is no less. In all we do, we reach for more -greater respect, fuller justice, deeper compassion, better care, less poverty. We are impatient to do better and hold ourselves accountable for continuous improvement in the services we offer. (Matthew 25:14-23; II Corinthians. 9:6; Revelations 21:1)

Vision Inspired by our Catholic faith tradition, Holy Healthcare will be distinguished by an unrelenting focus on clinical and service outcomes as we seek to create excellence in the care experience. Holy Healthcare will become the most trusted health partner for life.

Team Healthcare


Appendix B. Models

Synchronized Analysis Model (Marker, 2007, p. 28)

Behavioral Engineering Model (Gilbert, 1978, p. 88)

Team Healthcare


Appendix C. Data Collection

Nursing Director Interviews

RN Director Interview Guide Date: Interviewer: Interviewee:

Question Response Please describe what Genesis is and what was the main purpose of implementing it at the hospital? Probe if needed: ● How was this message shared with the RNs?

● Do you believe the purpose has been reached?

How has the new online orders management process changed hospital processes? Where have you noticed the biggest impact? Probe if needed:

How has the transfer process been impacted?

How has the handoff process been impacted?

Do you have anyone who has truly been an exemplary performer since the implementation? Why have they embraced this change so well?

What type of support was originally given to the RN staff to learn the system and what support is given today? Probe if needed: ● How was training given? ● How is the information kept up?

● What is your role in this support?

What are some of the barriers that you believe might be stopping the RNs from doing the orders management process in the EHR? Probe if needed:

Do the RNs have the skills to use the system?

Do the RNs have the knowledge to use the system?

Are the nurses motivated to do the orders management process?

What are the consequences for not keeping up the EHR? Who is responsible for making sure these consequences don’t occur? Probe if needed: ● How would a nurse know when he/she isn’t meeting standards?

● Who monitors standards?

When I talk to the nurses, what do you believe they will say if I ask them what they need to be successful in complete the orders management process on a consistent basis?

What else would you like to share about this current situation with the EHR?

Team Healthcare


RN Director Interview Guide Date: 10/08/2013 Interviewer: Angie Wolthuis Interviewee: Director of ICU

Question Response Please describe what Genesis is and what was the main purpose of implementing it at the hospital? Probe if needed: ● How was this message shared with

the RNs?

● Do you believe the purpose has

been reached?

Purpose –INFO and MVTN it was a top down initiative, but the nurses do not care about the WHY. INFO and MTVTN I don’t know that they fully understand the purpose, however, it does not matter. They know those types of decisions cannot be changed, so they want to quickly incorporate it into their practice so they can continue to do good work.





The nurses have done a good job adjusting to the new EHR. INFO The whole process is electronic now, which is a huge change. In the past the nurses charted in Meditech, but the orders were not in the chart. Meditech was different as well because we had the ability to make changes based on our needs. We could ask for a change and it would happen in a day (changes to help with workflow, etc.). The new system is a universal system for the entire corporation, so one change is huge because it impacts everyone. ORG We can no longer make changes based on our needs. ORG We can make requests, but there are not guarantees as to if the changes will be made or not. This change of not really having any say in the way the system works is huge. ORG The system used to work for us, now we work for the system. Cerner designed the system for Evidence-Based Practice (EBP). EBP is one size fits all. ORG The system is not bendable; the culture has to bend to fit the system. It has changed INFO the transfer process because it is a disruption in the workflow. There are interruptions by the system (EBP reminders, etc.) – interruptions disrupt the thought process and it takes time to get back on track. Nurses are used to getting focused and completing a task, now they are RSRC constantly interrupted by the system reminding them to do things. There is also SO much information on a chart. It is difficult to sort through all the information.

What type of support was originally given to the RN staff to learn the system and what support is given today?

KNWLDG The training was all done in a “fake” environment. It was all theoretical. We were not able to use a live system and practice on real charts. The real learning happened on the day of the go-live. It is impossible to teach everything in the training – you just cannot prepare people for every situation they will encounter in

Team Healthcare


Probe if needed: ● How was training given?

● How is the information kept up?

● What is your role in this support?

the real world. A lot of people are tactile learners and will only learn by actually doing it. Another issue with the training was that ORG the people doing the training were not nurses. They were non-clinicians, so their brains process differently. It would be more effective if it were clinician to clinician training. The ones that were more effective that were not clinicians were educators (there was a gentleman that was a former teacher). He was effective because he understood how to teach. He had a training background. INFO and RSRC The directors disseminate all of the information to the nurses. Job aids come from somewhere… not sure where and we are expected to get them to the nurses. They are difficult to understand and way too long. INFO We don’t know who to contact to implement changes or who to talk to about training. (Angie: I followed up with, what about the Clinical Informatics Department - don’t you have a relationship with them?) I don’t know what the relationship between the hospital and the CID should be. INFO I don’t even know who to contact for training support or questions. I am a director, if I don’t know who to contact, how will the nurses know who to contact. ORG We don’t even know who our support from the CID should be. Shellie does something, but I am not sure what. We have no on sight support. The main location has a number they call and they get at the elbow, we have no at the elbow. We don’t even know who to call to ask for help.





There are huge generational differences in the nurses. The younger generation is great with technology, but the older generation is experienced. For the experienced RNs, there has been a huge cultural shift. They were experts and now they are novices. KNWLDG I think some of the RNs do not feel confident in their computer skills; it has made them question their abilities as nurses.

What are the consequences for not keeping up the EHR? Who is responsible for making sure these consequences don’t occur? Probe if needed: ● How would a nurse know when

he/she isn’t meeting standards? ● Who monitors standards?

Patient safety is compromised. There are time delays. RN Consequences – the process implemented is not the RNs fault. We use Just Culture in the organization and we try to find out the root cause and understand why something is not working. MTVN We don’t punish people unless they are intentionally doing something that will harm patients.

Team Healthcare



1:1 help –KNWLDG they need an expert with them. They never had a real expert at their elbow. They had had super users on the floor, but these were not necessarily experts in the process. If every nurse could have 1:1 help for a month – to ask about any situation that may arise (as not all situations arise every day), they could be consistent. They also need tools that are readily available. The job aids are on a website, but everything is there. RSRC If you are in a hurry, you do not have time to sort. I don’t have time to sort through them, I know a nurse does not have time to sort through them. There is too much information there. RSRC They need simple job aids with bullet points – do this, do this, do this. Not 15 page documents with step by step instructions, including the why they are doing it. It needs to be succinct. They need to be able to get to them quickly – one click, not fifteen clicks.

What else would you like to share about this current situation with the EHR?

RSRC The directors are responsible for auditing the charts, which adds even more to an already huge workload. RSRC We don’t know who to contact to implement changes.

Team Healthcare


RN Director Interview Guide Date: 10/08/2013 Interviewer: Angie Wolthuis Interviewee: Director of Medical Unit

Question Response

Please describe what Genesis is and

what was the main purpose of

implementing it at the hospital?

Probe if needed:

● How was this message shared with the RNs?

● Do you believe the purpose has been reached?

The purpose of implementation is to have a “flow” of information. In the past,

there was a paper chart and only one person could have access to that chart at a

time. With an electronic chart, there should be a more seamless flow of

information and anyone can have access to any chart at any time.

MTVN The RNs are mourning the loss of paper, particularly those that have been

in practice for a long time, but INFO the information is flowing and they

KNWLDGE understand the purpose. The purpose has been reached, but it does

not mean that they are not still adjusting to the huge change.





INFO Everything has changed related to how the nurses do their work. There is

bedside medication administration – they scan a wristband on the patient when

they administer the meds. This slows things down for the nurses.

During the transfer process, the INFO information is easier to see. The nurses can

see everything that was done on the patient in the other unit.

I can’t think of an exemplary performer in this area because there are so many

variables. There are some that are comfortable with the documentation piece,

but the lack in other areas. The thing about this change is that the nurses that

were excellent nurses MTVN now feel like they are starting over. They are MTVN

unsure about themselves. They are still great nurses, but they INFO computer

has thrown them off and made them MTVN question themselves. Some of the

newer nurses are better at the computer piece of things, but they still need to

KNWLDG build their skills in other areas.

The biggest challenge is that MTVN experienced nurses now feel like novice

nurses. ORGIt has been a very difficult cultural change.

Team Healthcare


What type of support was originally

given to the RN staff to learn the system

and what support is given today?

Probe if needed:

● How was training given? ● How is the information kept up? ● What is your role in this support?

The nurses KNWLDG had training in a classroom and then “at the elbow” support

from Super Users.

There are ongoing changes in the system. INFO We (the Directors) get updates

on the system or processes from the corporate office about once a month (via

email) and then we are expected to disseminate the information to our staff

members. They send everything to us (the Directors) including job aids.

The only support we have now for training, other than the updates from

corporate, are the INFO Super Users that are on our floors. However, they have

gone back to their jobs, so they are not receiving ongoing training in the system.

Corporate will be back on site to do advanced training next month.





RSRC Time can be a barrier – pressure to get the patient transferred out. This is

mostly related to the transfers that come to us from the Emergency Department.

MTVN Resistance – sometimes they don’t see the need to do the orders

management (when transferring). However, when we get the patient in our unit

and the orders haven’t been cleaned up, we don’t know what orders are current.

Discontinuing orders is a culture change. Previously, there was a paper chart.

MTVTN When a patient was transferred, you just turned the page and started

new orders and ignored the previous page. You could go back and refer to the

orders on the previous page, it didn’t feel as final as it does now, when you

discontinue in the system. There is something final about clicking delete in the

EHR. Even though we can still refer to the orders, it is a mindset change. INFO

Also, nurses don’t make changes to orders- that is supposed to be the role of the

doctor. I think some nurses feel like that by deleting the orders they are

practicing outside their scope – even though they aren’t. It is just such a cultural

change.

What are the consequences for not

keeping up the EHR? Who is responsible

for making sure these consequences

don’t occur?

Probe if needed:

● How would a nurse know when she isn’t meeting standards?

● Who monitors standards?

INFO Their peers will let them know – peer feedback. INFOThe receiving nurse

will call the transferring nurse and ask for clarification, which takes time. This

doesn’t happen all the time, but it is a consequence.

VOICE reports- if someone thinks something is unsafe they will report it in the

VOICE system (this is an anonymous system where employees can report safety,

ethics, and other violations).

INFO If there are real problems, the nurses will also communicate that to the

Directors when we round the floors.

Team Healthcare



RSCRC More time – not to feel so much pressure about time.

KNWLDG Better knowledge of the system and the processes.

INFO We need to reiterate the message that it is okay (in reference to the earlier

comment about it being the doctor’s job) to clean up the orders – we need a

clean slate when the patients come to our floor. This helps everyone do their job

better.

What else would you like to share about

this current situation with the EHR?

Team Healthcare


Emergency Room Nurse Interviews

Nursing Questions Unit Nurse is on: Emergency Department Any experience with EHR in past? Yes, but not Computerized Physician Order Entry

1. Why did the hospital move to the Electronic Health Record (EHR)?

2. How has the implementation of the EHR impacted the time it takes to transfer a patient (as an admit to the floor)?

3. When transferring a patient to the floor, whose responsibility is it to clean up the orders (e.g. discontinue, complete, etc.)?

How comfortable are you cleaning up orders?

Has the process been document or explained to you?

4. If you had trouble with the EHR system, not the computer itself, but questions on the process, do you know who to contact for support?

Would you contact someone for support if you knew who to contact?

5. Do you know how to locate the job aids that were made to help you with the EHR?

6. Help me understand how hard or easy it is to find information on the charts? Is it easy or hard to sort through information?

7. What is your comfort level using the computer?

8. If you don’t clean up the orders before you send the patient to the floor, what happens?

ADDITIONAL QUESTION (For RN Supervisor only) What kind of feedback do the nurses get if they do not complete the transfer process correctly?

What is the feedback from the supervisor or leader if they do not complete their orders before the transfer?

Team Healthcare


Team Healthcare


Nursing Questions- Nurse #2 (Supervisor) Unit Nurse is on: Emergency Department Any experience with EHR in past? Yes, but not Computerized Physician Order Entry


MTVN This was an initiative from the corporate office. To meet certain standards with the federal government, they had to go electronic. I don’t know if there are better systems out there, but everyone in health care will be in the same boat. I think for some things it is better (you don’t have to look for the patient’s chart), but for other things, it is not that great. INFO We will just have to figure it out.


It has definitely slowed things down. RSRC It takes more time to do pretty much everything and in the ER, that is rough.




It depends; there is some drama around this. INFO The charge nurse is supposed to do the admit orders, so it can be a little unclear about who is supposed to do the other pieces. The nurse, in theory, should discontinue and complete orders, but they don’t always do it. MTVTN I would not say they are all comfortable with discontinuing orders. When we had training – KNWLDG it seems like they just “skipped over” this. I am INFO not sure if it is very clear as to what is okay and what is not okay.



We would go to someone in our department – or Shellie (someone local that does not have the primary responsibility for training). INFO I don’t think that anyone knows how to get a hold of the people in the main location. I may call them if I needed help, but I don’t know how to get a hold of them.


Hmm, job aids – I know what you mean, but I have RSRC no idea where they are. I don’t know if they would be helpful because things move so fast, I don’t really have time to refer to something that is that long – their job aids are long.

Team Healthcare



When we get the patient, it is easy as we are the first point of contact. INFO However, finding infor on the charts can be confusing. The other day we had an MD call us from the Health Plaza. He had a little boy that had been in the ER and wanted to know about the X-Ray we did on him.


KNWLDG I am fine using a computer – this is just a totally different system than I am used to.


MTVN It depends. Sometimes the floor calls us – other times they just figure it out.

ADDITIONAL QUESTION (This nurse is a supervisor in the ER)

9. What kind of feedback do the nurses get if they do not complete the transfer process correctly?

What is the feedback from the supervisor or leader if they do not complete their orders before the transfer?

INFO If we catch anything as supervisors or charge nurses, we will talk to them. Patient safety is the most important thing to any nurse, so we want to make sure the patients are taken care of and safe. INFO We don’t really have a system in place to check to see if the orders are taken care of before they are transferred. Again, I am not sure if anyone knows whose job it is. It is not the MD’s job to do it in the system – they wouldn’t have time. The nurses should be doing it, but if they aren’t, they may not know it is their responsibility.

Team Healthcare


Nursing Questions- Nurse #3 Unit Nurse is on: Emergency Department Any experience with EHR in past? Quite a bit of experience, but not Computerized Physician Order Entry


Every hospital and health care organization has to move to an computerized charting system. MTVN It is a part of Obamacare.


I have quite a bit of experience with electronic charting, so I don’t think it has really changed the time it takes me. RSRCS It may take a little more time, but not much.




INFO The nurses are supposed to clean them up, I think, but it probably doesn’t always happen. It gets a little confusing with the holding orders, the admit orders, and the ER orders. It can be confusing as to who is supposed to do what. KNWLDG The process hasn’t really been explained; maybe it has, but I forgot. We had so much to learn, that is just one piece of it. I can’t really remember what they told us. (Future opportunity: Training)



INFO Not like a formal help line or anything. I would maybe call someone if there was a number for support.


RSRC I know they showed us where they are, but I don’t remember.


KNWLDG Finding information can be tricky, but I have a lot of experience, so I am fine.

Team Healthcare



I am pretty experienced, so I am good with it.


INFO It depends. Sometimes the floor calls us – other times they just figure it out.

Team Healthcare


Training Department Interview Guide

Date: Interviewer: Interviewee:

Question Response

What experience do you have in using the EHR? Did you work with any of the nurses or managers to create the training? How was the course piloted before the roll out and to whom?

Who participated in the training? Probe if needed:

Was this mandatory training?

Did the managers have to participate? Do you know if you had 100%

attendance? Do you have records?

What were the course objectives for this training? (goals)

Probe if needed:

Who set the course objectives?

Were there any constraints such as limited of time, space, budgets to providing this training? Describe them.

Describe what training the nurses had on the orders management process during transfer. Probe if needed:

Describe how you showed or demonstrated to your participants how to use EHR.

Were they trained on workflow process

or only functionality?

What type of hands on practice did your audience get during training? Did they get on the computer and actually practice?

How did the nurses know if they were doing the orders management process correctly during training? (What type of feedback did they get?)

Describe to me how your participants were evaluated to determine competency of what they learned?

• During the training did you discuss the why of orders management?

• Do they understand why they need to

Clinical Informatics Department Trainer Interviews

Team Healthcare


complete and/or discontinue the orders?

• Was there any hesitation when it came to orders management on the part of the nurses?

• If so, why were the nurses hesitant?

What was the support plan for nurses after training? Probe if needed:

• Are there job aids available on the topic or orders management during transfer?

• How do they access the job aids?

• Who do they contact for support? Do

they have access to help from the CID team and how do they know who to contact?

• How often do you get calls from the

Other Location nurses?

• What would you say the majority of those calls are about?

• Do nurses have the option to take

advanced training? If so, is orders management during transfer part of this training?

What does that advanced training cover and how does it cover that material (hands-on training, scenario-based)?

Do you have any feedback from your participants about how confident they felt about completing an EHR after training?

Team Healthcare



Date: 11/8/2013 Interviewer: Angie Wolthuis Interviewee: Trainer D

Question Response

What experience do you have in using the EHR?

Did you work with any of the nurses or managers

to create the training?

How was the course piloted before the roll out

and to whom?

I worked on this project and previous ones with this same health system.

The content has been adjusted based on upgrades and feedback, but most of

the content comes from the parent company and was piloted long ago; if it

was piloted at all.

Who participated in the training?

Probe if needed:

● Was this mandatory training?

● Did the managers have to participate?

● Do you know if you had 100%

attendance? Do you have records?

KNWLDG All staff – RN, ancillary, billing, coding, registration, MDs, mid-

levels, etc.

The training was mandatory – everyone was paid for their time in training.

Yes, the managers participated in training as well.

If people did not attend, they were not allowed to work, so I think it is safe to

say we had 100% attendance.

What were the course objectives for this

training? (goals)

Probe if needed:

● Who set the course objectives?

● Were there any constraints such as

limited of time, space, budgets to

providing this training? Describe them.

We wanted the people going through training to be proficient in both

functionality and integrate it (the EHR) into their workflow process.

.

There are always time constraints – get everyone trained in a couple of

months, ready to work for the go-live. There is always a limited budget as

well in a non-profit healthcare organization. We had to work with what we

had and do the best job possible. (Future opportunity: Training)

Describe what training the nurses had on the orders management process during transfer.

Probe if needed:

● Describe how you showed or

INFO A lot of orders management falls on the Doc, so we don’t hit orders

management too hard in the classes. INFO They can do some orders

management over the phone with the doc, but it is really the job of the Doc,

so we don’t go over it too much. ORG The problem is, in the other location,

Team Healthcare


demonstrated to your participants how

to use EHR.

● Were they trained on workflow process or only functionality?

● What type of hands on practice did your

audience get during training? Did they

get on the computer and actually

practice?

● How did the nurses know if they were doing the orders management process correctly during training? (What type of feedback did they get?)

● Describe to me how your participants

were evaluated to determine

competency of what they learned?

• During the training did you discuss the

why of orders management?

• Do they understand why they need to

complete and/or discontinue the orders?

• Was there any hesitation when it came

to orders management on the part of the nurses?


they chose to do a different process than the main location on transfer from

the Emergency Department to an Inpatient department. The main location

has a “holding” area for patients and all their orders drop off after they leave

the ER. In the other location, their orders stay on the chart. I don’t know

why they chose to do that. It is a huge problem because the RSCR ER nurses

don’t have time to clean up the orders, yet it is supposed to be their job.

The nice thing is, at the main location they start with a clean slate. In the

other location, RSCR the chart is still full of orders and they are relying on

humans to clean the orders up – that human component is the wild card.

We did a presentation and then had the nurses do some hands-on practice.

KNWLDG They practiced both functionality and process. They had fake

patients that were prepped with orders so they could practice the scenarios.

I remind nurses of INFO he policy: use reason, logic, and good faith and you

will know if the decision you are making related to orders management is

correct. ( Team: Is this really the policy?)

The why we discussed was that when there is an order it generates a task for

the nurse. If you don’t clean up the orders, as a nurse, you are actually

creating more work for yourself by there being more tasks generated. MTVN

They understand the why, but I don’t know if they buy into it.

The hesitation is that it is not all their job. Part of it is the doctor’s job. It is

also a generational thing. KNWLDG Some RNs are more comfortable with

computers. INFO Some of the more tenured nurses also feel like it is outside

their scope of practice. I tell them not to think of the Orders tab as the

“orders” tab – they look at that as physician-driven. I tell them to think of it

as the engineering deck, not the orders component. This is where all other

tasks, etc. are “engineered” from.

What was the support plan for nurses after

training?

Probe if needed:


• How do they access the job aids?

We have been begging for advanced training forever and we are finally

getting it. KNWLDG They need more training on patient care, upgrades, etc.

There are RSCR job aids in Sharepoint. We do tell them in class how to access

the job aids. There is also a Guide Me function in Cerner now. This is really

high-level stuff from the parent company, but it is new and can be helpful.

Team Healthcare


• Who do they contact for support? Do

they have access to help from the CID team and how do they know who to contact?

• How often do you get calls from the Other Location nurses?


• Do nurses have the option to take advanced training? If so, is orders management during transfer part of this training?

● What does that advanced training cover

and how does it cover that material

(hands-on training, scenario-based)?

They contact 5448 for help, which is our team (CID team). We told them in

class to contact that number for support. That should be their first line of

defense. After that, they should contact their site liaisons, but they are so

busy with physician issues, they don’t have time to help. INFO I actually don’t

know which site liaison there would help with RN issues. I am not sure they

know who to contact there. I don’t think the liaisons understand their own

roles.

We rarely get calls from the other location. The majority of them are system

access requests (password help, etc.). ORG the other location is typically

dismissive and rude to the mian location people anyway. They are not open

to “help” from the main location – it is like they have something to prove.

They don’t listen when I try to help them.

MM is responsible for helping put together the advanced training; I am not

sure what they will cover, but I suppose orders management will be in there.

All the nurses will eventually take it.

Do you have any feedback from your participants

about how confident they felt about completing

an EHR after training?

INFO Not really, as I said – it is really the job of the Doctor.

Team Healthcare



Date: 11/18/2013 Interviewer: Angie Interviewee: Trainer P

Question Response

What experience do you have in using the EHR?

Did you work with any of the nurses or managers to create the training? How was the course piloted before the roll out and to whom?

I was hired to help with the implementation. The training was already created and I believe it was created by the Holy Healthcare, the parent company.

The hospitals have been using the same content for all of the go-lives in the system, so it was not piloted at our site.

Who participated in the training? Probe if needed:

Was this mandatory training?

Did the managers have to participate?

Do you know if you had 100% attendance? Do you have records?

KNWLDG There was training for everyone working in the hospital: Provider training, RN training, ancillary services training, billing training, registration, etc.;(team note: no orders management?) they were all split out by what they did. Training was separate for each “group” of people and all managers were required to participate.

Training was mandatory and people were not allowed to work until they completed the training.

There had to be 100% attendance as anyone that didn’t attend was not allowed to work.

What were the course objectives for this training? (goals)

Probe if needed:

Who set the course objectives?

Were there any constraints such as limited of time, space, budgets to providing this training? Describe them.

There are too many objectives to cover. We really wanted them to be able to use the system and be confident in their abilities to do so. The course objectives were set by the parent company. We had time constraints for sure. We had to get everyone trained by the go-live and had just a couple of months to do it. There are always budget constraints, but the nurses were paid for the training and if they needed additional training, they were paid for that as well. (Team: Note for future opportunities training improvement)

Describe what training the nurses had on the orders management process during transfer. Probe if needed:

Describe how you showed or demonstrated to your participants how to use EHR.

Were they trained on workflow process or only

INFO Orders management is the job of the provider (doctor). The nurses are there to facilitate it (they can take the orders to do it over the phone or verbally), but it is really the responsibility of the provider. If they are going from the Emergency Department to Inpatient the nurses call the physician they are admitting the patient to and let that MD know. The admitting MD goes through the meds. KNWLDG The nurses were trained on both process and functionality. The

Team Healthcare


functionality?

What type of hands on practice did your audience get during training? Did they get on the computer and actually practice?

How did the nurses know if they were doing the

orders management process correctly during training? (What type of feedback did they get?)

Describe to me how your participants were evaluated to determine competency of what they learned?

• During the training did you discuss the why of

orders management?

• Do they understand why they need to complete and/or discontinue the orders?

• Was there any hesitation when it came to

orders management on the part of the nurses?


practice was process, but of course we could not cover every situation in training. The KNWLDG RNs did get hands-on practice. They were all assigned to a workstation and they used them during the class. We had fake patients loaded with real data, provided to us by the parent company and created by real nurses. INFO I wouldn’t say we gave them feedback during training about that – we just really hammered things hard during our presentation. They were given quizzes at the end of each section. If they didn’t pass, they had to have more individualized training with a trainer. KNWLDG Eventually, everyone had to pass in order to go back to work. (team how do we know?)

The why was discussed – keeping the chart clean so that there are no mistakes with possible duplicate orders, etc. MTVTN However, nurses see orders management as “not my problem”. If they are the transferring nurse (particularly from the ED to inpatient), they see that the receiving nurse will be responsible for the care of the patient and will therefore be the scapegoat if there is a mistake. ED nurses say they do not have time to do the orders management process. RSRC The hesitation is time. It takes too much time and they INFO and MTVN feel some of it is out of their scope of practice.

What was the support plan for nurses after training? Probe if needed:


• How do they access the job aids? • Who do they contact for support? Do they have

access to help from the CID team and how do they know who to contact?

• How often do you get calls from the Other Location nurses?


• Do nurses have the option to take advanced training? If so, is orders management during transfer part of this training?

What does that advanced training cover and how does it cover that material (hands-on training, scenario-based)?

The nurses were given at the elbow support from super-users for approximately a month. After the support went away, RSCRS they were told to call ext. 5448, which is the CID team (support team). That number is RSRC available M-F 7am to 7pm and there is someone on call on the weekends as well. We do get calls from Other Location nurses. I remote in on their computer and sometimes look to see what the problem might be. This allows me to see their screen and what they are working on. The calls are mostly about charting. There are job aids on a Sharepoint site. RSCS I would say there are at least 100 job aids. There is probably too much info for them there and I have been told that they easily get sidetracked on the site and it is probably hard to find exactly what they need. They will be required to take advanced training in the next couple of months. They will be paid for their time in advanced training. I am not sure that everything is finalized on what the advanced training will cover, but I am sure it will be hands-on.

Clinical Informatics Department Liaison Interviews

Team Healthcare


Question Data Source Answer

1. On a transfer who holds the primary responsibility for orders management during the transfer process?

(The physical process in the EHR, not responsible for determining which orders continue or not.)

2. Are the nurses doing it? If not, why do you think the nurses are not doing the orders management during the transfers?

3. Do you have any evidence that tells you they are not doing it?

4. What do you do with the

evidence that this the orders management is not being done?

Team Healthcare


Question Data Source Answer

1. On a transfer who holds the primary responsibility for orders management during the transfer process?

(The physical

process in the EHR,

not responsible for

determining which

orders continue or

not.)

2. Are the nurses doing it? If not, why do you think the nurses are not doing the orders management during the transfers?

3. Do you have any evidence that tells you they are not doing it?

4. What do you do with the evidence that this the orders management is not being done?

Physician Liaison

Clinical Informatics

Department

1. INFO The nurses, they don’t do it, but it is their job.

2. INFO I think there has just been so much going on and no one is really clear on what their role is. Each hospital is different, so that can be challenging as well. ORG They have their own policies and sometimes our team is not even 100% clear on who is supposed to do what in each hospital.

3. INFO We audit the charts from time to time for our purposes, but in my audits, I have noted that the orders from the Emergency Department were not “cleaned up” as they should have been. I just did an audit last week and 3 out of the 4 charts were not properly updated.

4. Since most of our audits are informal, and more for the purpose of gathering information, I don’t do anything formalized with the information. My primary responsibility is to work with providers (physicians and mid-levels), and if there is something that is directly affecting them, it becomes my problem to solve. INFO At this point, I just noted the information and may bring it up to colleagues if it seems to be an issue.

Orderset Coordinator


Department

1. INFO The nurses should be doing it – the actual in the computer piece. They obviously consult with the MDs on this, but they should be completing or discontinuing orders; cleaning them up.

Team Healthcare


2. INFO No, they are not consistent about it at all. I think they just aren’t sure about what their responsibilities are when it comes to this process.

3. Our department does chart audits from time to time and since I used to support the Emergency Department in the main location I look at ED stuff. Last week we all did some independent audits (your project has brought some awareness to this topic) and I found that 3 out of the 5 charts were clearly not updated properly before the transfer.

4. While my job is to review orders, it is merely for the purpose of making sure the orders that we built (the organization builds ‘sets’ of orders) are working correctly. I review the ordersets or the PowerPlans and note any issues with those. I noticed this in my audits because you asked us about it. INFO I merely gathered the information for you and we will probably note the information as a department and disseminate it to the directors at all sites.

Clinical Liaison


Department

1. INFO The nurses should be doing the clean-up in the charts, I suppose. Really, I think the doctors should do it, but everyone says that since they won’t do it, so it falls on the nurses. That is typical – the nurses come behind the docs and clean up their messes! In this case, the nurses should be doing the clean-up after they have consulted the providers on what orders should and shouldn’t continue.

2. ORG I don’t think they are doing it in the other location like they should be. It is probably something that was lost in translation during the whole go-live process. We may need to go back and clarify things to them.

3. Yes, I am responsible for looking at clinical issues within the system. While I am not the clinical liaison for that site, I do look at issues in the system as a whole and it was recently brought to my attention, through some audits, that orders are not being properly managed during the transfer process (and in general). This is on my radar now. (Follow-up from interviewer: In the audit process, how many charts would you say are updated correctly during the transfer process?) I would say probably about 25-30% are correct. That is nowhere near where it needs to be. I would like to see 100%.

4. I did the audit at your request. INFO We did note the issue and will bring it up at IOT (a meeting that involves people from the corporate office as well as local leaders – they assign problems for resolution and report on those at this meeting). We have brought it up before, but the other location does not always have a representative at the meeting. They are always invited, but they are also in the middle of building a new “hospital” (heart care unit and maternity unit) and they have been working tirelessly to get this done. I will communicate the issue to them again and discuss it with their clinical liaison.

Clinical Educator

Clinical Education

Department

1. The nurses should do the orders management, but it can be a complex process. There are holding orders, admit orders, and current orders. It can be a little tricky to know who is supposed to do what.

2. From what I observed during the observations, they are “kind of” doing it. They are doing it to a point, which is why I checked “yes” on the observations, but they are not completely doing the entire process. Now that I think about it, I should have probably made more notes on the observations that talked about how they didn’t fully complete the process.

Team Healthcare


3. The only evidence I have is the comments I have from Directors or the receiving floors telling me that the orders are not cleaned up. We did have one incident where there was some confusion with which orders were current and which were not – it could have been a deadly situation, but it wasn’t. One near miss is enough.

4. It is not necessarily my job to fix this issue, but I do bring it up to the directors. I also was hoping you (Team Healthcare) could bring us some recommendations!

Charge Nurse

Emergency Department

1. I suppose it is the nurse’s job– well I am pretty sure it is, but it doesn’t get done like it should. It just doesn’t.

2. They are not doing it like they should. I think some of them know, but don’t have time and others are just not sure what is their job and what is the job of the MD.

3. When I charge (work as the charge nurse), I put in the admit orders and I see all the charts. From seeing these charts I know that they are not doing it. (Follow-up from interviewer: How many charts, out of every 5, would you estimate, do not have the orders cleaned-up like they should be?) Probably 3 out of every 5 do not have the orders cleaned up. Maybe even 4 out of 5. They are pretty consistently not cleaned up.

4. I do bring this up at huddle, but at this point I think I need the process and the responsibilities clarified myself.

Team Healthcare


Observation Checklist and Data

Before conducting your observation please take a moment to familiarize yourself with this checklist so

that your observation will go smoothly.

Step 1: Complete the following demographics information

Observation Details

Name and title of person conducting

the observation

Date of observation

Time of observation began

Time checklist was completed

Titles of who is being observed

Step 2: Observe the subjects and complete this checklist during the observations.

**Note of important terms: EHR (Electronic Health Record) and Subject (the people under observation).

During your observation did the

nurses do the following:

Yes No Comments

Conduct a verbal hand off?

Meet with MD who told them it was ok

to discontinue orders?

If they did not update the orders or

meet with the MD ask follow up

questions:

a. Is it common or not common that you meet with the MD and get the ok to clean up orders?

b. How do you feel about not getting the ok from the MD to complete the orders?

c. How comfortable would you be cleaning up the orders without the MD’s approval?

Use the EHR to complete the verbal

pass down? Did you see them walk

to the computer and type in

information?

Use a computer in another area to

view the EHR? Please comment

where.

Where did they go use the computer?

Update the EHR after the hand off?

Show any concern through verbal or

nonverbal actions their frustration

with using the EHR?

Team Healthcare


Team Healthcare


Informal Interview of Nurses Results

Below is the data the team collected from informal interviews conducted verbally with 6 Holy Medical Center nurses. Question Medical

Floor Nurse

Medical Floor Nurse

Medical Floor Nurse

ICU Nurse

ICU Nurse

ICU Nurse

Average

1.

On a scale of 1 to 5, 5 being really well and 1 being not well at all, how well does the transfer process, including the “computer” piece of it, work?

2 4 3 4 5 5 3.83

2.

On a scale of 1 to 5, 5 being really well and 1 being not well at all, when you receive a transfer patient to your unit, how well are the orders cleaned up in the chart (orders that are no longer relevant have been discontinued)?

3 2 1 3 2 2 2.17

3.

On a scale of 1 to 5, 5 being really well and 1 being not well at all, typically, how well does the verbal handoff process go between nurses (how thorough is it)?

4 3 4 5 4 3 3.83

4.

On a scale of 1 to 5, 5 being always and 1 being never, how often do you open the patient’s chart during the handoff process and review with the transferring nurse (either on the phone or in person)?

5 5 5 2 4 3 4

5.

On a scale of 1 to 5, 5 being I completely agree, and 1 being I do not agree at all, I understand my role in the orders management process (cleaning up orders) during a transfer.

2 4 4 3 3 1 2.83

Team Healthcare


Results of Informal Poll with Nursing Directors and Clinical Educator

Below is the data collected from informal interviews conducted verbally with 2 nursing unit directors and the clinical educator at Holy Medical Center.

Question ICU Nursing Director

Medical Floor

Nursing Director

Clinical Educator

Average

1. On a scale of 1 to 5, 1 being not well at all and 5 being very well, how well does the transfer process work overall?

3 3 2 2.67

2. On a scale of 1 to 5, 1 being not well at all and 5 being really well, how well do the nurses perform the transfer handoff process?

3 3 3 3

3.

On a scale of 1 to 5, 1 being not well at all and 5 being really well, how well are the orders “cleaned up” in the patient chart when you receive a patient on your floor?

3 3 3 3

4. On a scale of 1 to 5, 1 being not well at all and 5 being really well, how well do the nurses complete the verbal portion of the handoff?

5 4 4 4.34

5. On a scale of 1 to 5, 1 being never and 5 being always, how often do the nurses open the electronic chart for review during the transfer process?

3 2 1.5 2.16

6. What percentage of the time do you think the nurses open the electronic patient chart during the transfer process (to review with the other nurse)?

50% 15% 15% 26.67%

Team Healthcare


ERIH Intervention Interviews

These interviews are not directly related to the performance gap, which is why they are not coded.

Follow-up Interviews (Intervention ERIH)

The purpose of these interviews is to help the team determine if the ERIH will eliminate the performance gap.

Questions Interviewee Response

Our team noted that there is an

ERIH area in the EHR at HC Regional

and the claims are that this holding

area eliminates the need for nurses

to do the orders management

process when they transfer a

patient from the ER to an inpatient

unit. Does the ERIH eliminate the

need for nurses to do orders

management during transfer?

Follow-up:

Based on what you have seen, does this eliminate any risk associated with possible human error during the transfer process (related to orders management)?

Do you know why Holy Medical Center chose not to include the ERIH in their system build?

Do you know if Holy Medical Center has the ability to add this functionality to their system?

Orderset Liaison Yes. I used to be the primary support person for the ER at HC Regional

and I used to work in the ER at HC Regional and having the ERIH makes

the orders just go away. The patient starts with new orders when they

transfer.

Yes – I am extremely familiar with the functionality and it literally dumps

the orders (they are obviously retrievable and a part of the permanent

record), but in the nurse’s mind, it is much more like the “old” paper

process. They are essentially turning the page.

No, I am not sure why they chose not to use it. My understanding is that

they had the option to use it, but chose not to.

I do not know at this point what it would take, we could research that and

find out.


Specialist (assigned to

support the ER at HC

Regional Medical

Center)

Yes, that is accurate; utilizing the functionality of the ERIH allows the

orders to go away upon transfer or “admit” to an inpatient unit.

There is essentially no risk, as there are no orders to manage. The ER doc

talks to the inpatient doc and they coordinate – the inpatient doc puts in

new orders, but can still ‘view’ the ER orders, if necessary.

I don’t know for sure, but most things are political. I am thinking they

came up with a process they thought worked for them and went with

that.

I do not know – I am sure it is there in the background. I don’t know what

it would take to get it up and running.

Team Healthcare


Clinical Educator

(involved in the ERIH

implementation at Holy

Medical Center)

From what I heard during the implementation, this is true. I have

observed at HC Regional and their process seems to go a lot more

smoothly than ours.

If it works the way I was told it would, the nurses would not have to do

orders management; thereby eliminating our problems. I completely

forgot about this.

I don’t remember – there were so many decisions to make and so many

variables, it is all a blur. I could probably find out though. It may take a

little digging!

I believe we do, but again, I would need to assess this and find out what

the associated costs are, etc.

Team Healthcare


Appendix D. Data Synthesis

BEM Data Synthesis

Major trend is large data points that will be addressed by interventions

Minor trend is minor data points that should be noted or used for future

Information

Instrumentation

Motivation

Data 62 overall pieces of evidence that causes are

steaming from data issues in the environment. Data extracted from 11 interviews

Resources 24 overall pieces of evidence that causes are steaming

from resource issue in the environment. Data extracted from 11 interviews

Incentives 3 overall pieces of evidence that causes are

steaming from incentives issue in the environment. Data extracted from 11interviews

Environment

Major trends:

Inadequate information about roles and responsibilities of the process was found in 17 pieces of evidence extracted from 10 interviews

Evidence of trend found in interviews:

#of comments

Trainer D 2

Trainer P 2

RN Director 1 1

Nurse 2 3

Nurse 3 2

Physician Liaison 1

Orderset Coordinator

1

Clinical Educator 2

Charge nurse 1

Nurse 1 2

Trainers P comments: They can do some orders management over the phone with the doc, but it is really the job of the Doc, so we don’t go

Major trends: Lack of time to complete the EHR was found in 7 pieces of evidence extracted from 7 interviews

Evidence of trend found in interviews

#of comments

Trainer D 1

RN Director 1 1

RN Director 2 1

Nurse 2 1

Nurse 1 1

Nurse 3 1

Charge Nurse 1 RN Director 1 comment Time can be a barrier – pressure to get the patient transferred out. This is mostly related to the transfers that come to us from the Emergency Department. RN Director 2 Comment : What the nurses need is More time – not to feel so much pressure about time. Trainer Comments D: I don’t know why they chose to do that. It is a huge problem because the ER nurses don’t have time to clean up the orders, yet it is

Minor trend: No consequence for poor performance was found in 3 pieces of evidence extracted from 3 interviews

Evidence of trend found in interviews:

#of comments

Nurse 2 1

RN Director 1 1

RN Director 2 1 Nurse 2 comments: If I don’t clean up the orders then someone on the floor calls us, other times they just figure it out RN Director 2 comments: The process implemented is not the RN’s fault. We don’t punish people unless they are intentionally doing something that will harm the patient. RN Director 1 comments: If they don’t do the chart right, their peers will let them know The receiving nurse will call the transferring nurse and ask for clarification which takes time. If there is a real problem nurses will communicate to the

Team Healthcare


over it too much Trainer D comments: A lot of orders management falls on the Doc, so we don’t hit orders management too hard in the classes. RN Director 1 comments: Also, nurses don’t make changes to orders- that is supposed to be the role of the doctor. I think some nurses feel like that by deleting the orders they are practicing outside their scope Nurse 2 Comments: Drama around roles. Charge nurse is supposed to do the admit orders so it can be unclear about who is supposed to do the other pieces. Nurses, in theory should discontinue and complete orders but they don’t’ always do it. Nurse 2 comments: We don’t really have a system in place to check to see if the orders are taken a care of before they are transferred. Not sure if anyone knows whose job it is. It is not the MD’sjob in the system, they don’t have time. The nurses should be doing it but they aren’t, they may not know it is their responsibility. Nurse 3 comments: Nurses are supposed to clean up the orders. I don’t think it probably doesn’t always happen. It can be confusing as who is supposed to do what. Nurse 3 Comments. The process ( of who should clean up orders) hasn’t been explained; maybe it has but I have forgotten. Nurse 2 Comments: I would not say they are all comfortable with discontinuing orders. Physician Liaison comment: I think there is so

supposed to be their job. Nurse 2 Comments: The EHR has pretty much slowed everything down (note: nurse has little to no experience in computerized physician order) Nurse 3 Comments: I have quite a bit of experience with electronic chartings so I don’t think it has really changed the time it takes me. It may take a little more time but not much. Charge nurse comments: It is the nurses job, well I’m pretty sure, but it doesn’t get done like it should. I think some of them know, but don’t have the time and others are just not sure what is their job and what is the role of the doctor. Nurse 1 comments: It takes a lot more time – a ton more time! I hate it. It is not intuitive, like they said it would be Major trends: Lack of adequate job aids was found in 6pieces of evidence extracted from 6 interviews


#of comments

RN Director 1 1

Trainer P 1

RN Director 2 1

Nurse 2 1

Nurse 3 1

Nurse 1 1 RN Director Comments: Job aids come from somewhere… not sure where and we are expected to get them to the nurses. They are difficult to understand

directors when we round the floors

Team Healthcare


much going on that no one is clear on what their role is. Orderset Coordinator Clinical Informatics comments: The nurses should be doing it, the actual in the computer piece. The obviously consult with the MD’s but they should be completing and discontinuing orders. Clinical Liaison comments: Nurses should be cleaning up the charts I suppose. Really I think the doctors should do it but everyone says that since they won’t it falls on the nurses. The nurses should clean up after they have consulted with providers what orders should and shouldn’t continue. Clinical Educator comments: Nurses should do the orders management. It can be tricky to know who should supposed to do what. Since I did the observations I realized although I said yes they are doing the orders management I should have said they are “kind of doing the process” Charge nurse comments: It is the nurses job, well I’m pretty sure, but it doesn’t get done like it should. I think some of them know, but don’t have the time and others are just not sure what is their job and what is the role of the doctor. Nurse 1 comments: I don’t discontinue stuff, I just know what he (the MD) wants me to do. I give the report of what has happened when I call the floor nurse; they can figure things out from there. Am I supposed to be cleaning up the orders? I suppose it might be my job, but I just worry about the ER orders and then I give info I have to the floor nurse.

and way too long. Trainer comments: There are job aids in Sharepoint. We do tell them in class how to access the job aids. There is also a Guide Me function in Cerner now. This is really high-level stuff from the parent company, but it is new and can be helpful. RN Director Comment: They need simple job aids with bullet points – do this, do this, do this. Not 15 page documents Trainer P comments: There are at least 100 job aids. Probably too much info for them there and I have been told hard to find exactly what they need. Nurse 2 Comments: I have no idea where the job aids are. I don’t really have time to refer to something that is that long. The job aids are long. Nurse 3 Comments: I know they showed us where they are but I don’t remember. Nurse 1 Comments: I have no idea where the job aids are. I supposed they told me, but I don’t know where to find them. I think they put them on a board or something. Not sure. Observations: 4 out of 4 nurses did not use job aids Minor trend: System not easy to use RN Director Comments: During the transfer process, the information is easier to see. The nurses can see everything that was done on the patient in the other unit.

Team Healthcare


Trainer D Comments Nurses feel some of it is out of their scope of practice Trainer P Comment: Some of the more tenured nurses also feel like it is outside their scope of practice. I tell them not to think of the Orders tab as the “orders” tab – they look at that as physician-driven Major trends: Lack of adequate feedback was found in 10 pieces of evidence extracted from 9 interviews


#of comments

RN Director 1

Observations 2

Trainer 1

Physician Liaison 1

Clinical Liaison 1

Charge Nurse 1

3 Nurses 3 Lack of feedback from Director to RN RN Director 2 comments We need to reiterate the message that it is okay (in reference to the earlier comment about it being the doctor’s job) to clean up the orders – we need a clean slate when the patients come to our floor. This helps everyone do their job better. Lack of feedback from Doctor to RN Observations 2 out 4 nurses did not talk to the provider during the orders management process

RN Director Comments: there is also SO much information on a chart. It is difficult to sort through all the information. Nurse 3 Comments: Finding information can be tricky but I have lots of experience so I am fine. Observations: Computers are not in the patients room must go somewhere else Nurse 2 comments: We don’t really have a system in place to check to see if the orders are taken a care of before they are transferred.

Team Healthcare


Lack of communication between trainers and RN

Trainer Comment: I actually don’t know which site liaison there would help with RN issues. I am not sure they know who to contact there. I don’t think the liaisons understand their own roles. Lack of feedback to RN’s about charting audits

Physician Liaison Comments: Since most of our audits are informal, and more for the purpose of gathering information, I don’t do anything formalized with the information. My primary responsibility is to work with providers (physicians and mid-levels), and if there is something that is directly affecting them, it becomes my problem to solve. At this point, I just noted the information and may bring it up to colleagues if it seems to be an issue. Clinical Liaison Comments: I did the audit at your request. We did note the issue and will bring it up at IOT (a meeting that involves people from the corporate office as well as local leaders – they assign problems for resolution and report on those at this meeting). We have brought it up before, but the other location does not always have a representative at the meeting. Charge Nurse Comments: I do bring chart audit info up at huddle, but at this point I think I need the process and the responsibilities clarified myself. Nurse #1 Comment: Nurses If you don’t clean up the orders before you send the patient to the floor, what happens? Sometimes they call us to clarify, other times, nothing

Team Healthcare


Nurse #2 Comment: If you don’t clean up the orders before you send the patient to the floor, what happens? It depends. Sometimes the floor calls us – other times they just figure it out Nurse #3 Comment: Nurses If you don’t clean up the orders before you send the patient to the floor, what happens? They seem to figure it out Major trends: Lack of information about support was found in 7 pieces of evidence extracted from 7 interviews This is also an information problem.


#of comments

RN Director 1 2

Trainer P 1

RN Director 2 1

Nurse 2 1

Nurse 3 1

Nurse 1 1 RN Director Comment: We don’t know who to contact to implement changes or who to talk to about training. RN Director Comment: I don’t know what the relationship between the hospital and the CID

Team Healthcare


should be. I don’t even know who to contact for training support or questions Trainer Comment: I actually don’t know which site liaison there would help with RN issues. I am not sure they know who to contact there. I don’t think the liaisons understand their own roles. RN Director Comment: The only support we have now for training, other than the updates from corporate, are the Super Users that are on our floors. However, they have gone back to their jobs, so they are not receiving ongoing training in the system. Nurse 2 Comments: We would go to Shellie (someone local that does not have the primary responsibility for training). I may call them (Main Location) if I needed help but I don’t know how to get a hold of them. Nurse 3 Comments: I don’t think we have a formal help line or anything. I maybe call someone if there was a number for support. Nurse 1 Comments: If I had problem would I call the help desk? No, not really. The help desk? Not if it isn’t about the computer. Hmmm…. No, I would just ask the charge nurse for help. I don’t know if I really care.

Team Healthcare


Knowledge 21 overall pieces of evidence that causes are

steaming from knowledge/skill issue from individual

Data extracted from 11 interviews

Capacity Motives 29 overall pieces of evidence that causes are steaming from motive issue from individual

Data extracted from 11 interviews

Individual

Major trends: Lack of adequate confidence to clean up orders .5 pieces of evidence extracted from 4 interviews


#of comments

Trainer D 1

RN Director 1 1

Nurse 2 2

RN Director 2 1

RN Director 2 Comments: The training was all done in a “fake” environment. It was all theoretical. We were not able to use a live system and practice on real charts. Trainer D comments: There is just a lot of information and they were nervous about things. RN Director 1 Comments: A lot of people are tactile learners and will only learn by actually doing it they didn’t get this. Nurse 2 Comments: In training they skipped over this (the role of who does clean up) so not sure if it was very clear Nurse 2 Comments: I would not say they are all comfortable with discontinuing orders.

Major trends: ** This is a diffusion effect steam from a lack of information

Inadequate motivation by nurses to clean up the orders. 8 pieces of evidence extracted from 7 interviews


#of comments

Trainer D 1

Trainer P 1

RN Director 1 1

RN Director 2 1

Nurse 1 1

Nurse 2 1

Nurse 3 1

Trainer D comments.. The why we discussed was that when there is an order it generates a task for the nurse. If you don’t clean up the orders, as a nurse, you are actually creating more work for yourself by there being more tasks generated. They understand the why, but I don’t know if they buy into it. Trainer P Comments: Nurses see Order Management as “not my problem”. The transferring nurse see that the receiving nurse will be responsible. RN Director 1 Comments: The RNs are mourning the loss of paper, particularly those that have been in practice for a long time, but the information is flowing and they understand the purpose. The purpose has been reached, but it does not mean that they are not still adjusting to the huge change.

Team Healthcare


Minor trend: Lack of computer skills RN Director Comments: They are still great nurses, but they computer has thrown them off and made them question themselves. Some of the newer nurses are better at the computer piece of things, but they still need to build their skills in other areas. Trainer D Comments Some RNs are more comfortable with computers. Some of the more tenured nurses also feel like it is outside their scope of practice. RN Director 2 Comments: I think some of the RN’s do not feel confident in their computer skills Nurse 2 Comments: I am comfortable with the computer. But this is just a totally different system than I’m used to. Nurses Comments: I am a geriatric nurse. It was humiliating to be in class with these young kids just zipping around in the system. I felt like I was back in school. It was awful. I am figuring it out though and I don’t think that is the case for most nurses. I don’t really think it is that big of an issue for most of the nurses in my department. Mostly me! 4 Nursing Observations showed all nurses using the computer with proficiency

RN Director 2 Comments: it was a top down initiative, but the nurses do not care about the WHY. I don’t know that they fully understand the purpose RN Director Comments – sometimes they don’t see the need to do the orders management (when transferring). Nurse 2 Comments: We went to EHR because it was an initiative from the corporate office. To meet certain standards with the fed government they had to go electronic. Nurse 3 Comments: We went to EHR because it part of Obamacare. Nurse 1 Comments: It doesn’t really matter to me. They had to – we can’t go back. The government is telling them they have to. I understand why, and I know we can’t go back. They why doesn’t really matter, I just want to make sure my patients are taken care of. Major Trend: ORG ** This is a diffusion effect steaming from a lack of information and inadequate resource support from sister company. Distrust is coming from supervisor roles primarily Distrust between Main Location/Other Location or Between Departments (10 pieces of evidence)


# of comments

Trainer D 2

RN Directors 7

Clinical Liaison 1

Team Healthcare


Trainer D comment: We rarely get calls from the other location. The majority of them are system access requests (password help, etc.). the other location is typically dismissive and rude to the main location people anyway. They are not open to “help” from main location – it is like they have something to prove. They don’t listen when I try to help them RN Director comment: The system used to work for us, now we work for the system. Cerner designed the system for Evidence-Based Practice RN Director comment: I don’t know what the relationship between the hospital and the CID in he main location should be RN Director comment Another issue with the training was that the people doing the training were not nurses. They were non-clinicians, so their brains process differently. RN Director comment: It has been a very difficult

cultural change.

Clinical Liaison I don’t think they are doing it in the

other location like they should be. It is probably

something that was lost in translation during the

whole go-live process. We may need to go back and

clarify things to them.

RN Director comment: We can no longer make

changes based on our needs.

RN Director comment We can make requests, but

there are not guarantees as to if the changes will be

made or not

RN Director comment: The system is not bendable,

the culture has to bend to fit the system

Trainer comments: The problem is, in the other location, they chose to do a different process than main location on transfer from the Emergency

Team Healthcare


Department to an Inpatient department

Team Healthcare


Appendix E. Supporting Documents

Training Agenda

Team Healthcare


Team Healthcare


Transfer Process Job Aid

Team Healthcare


Team Healthcare


Meeting OPWL Program’s Learning Outcomes

Conduct the HPT process in a way that is systematic

A systematic HPT process is a carefully planned, deliberate effort that uses appropriate methods of problem definition, data collection and data analysis to minimize the likelihood “errors and omissions”, that is, of not discovering vitally important information regarding a performance problem and/or misconstruing what evidence is gathered. Rummler and Brache (1995) state that organizations are systems but that many managers of these systems fail to recognize customers, product/service or workflow. As nascent HPT professionals, we do not want to make this same mistake!

Therefore, to insure our assessment will be as systematic as possible, the Team applied the principle of the “Seven Ps”, Proper Prior Planning Prevents Pitifully Poor Performance to our efforts. Specifically, before meeting with the client, the Team:

● selected a Needs Assessment model – the Behavior Engineering Model (Gilbert, 2007) with additional perspectives and concepts suggested by Marker (2007) and Langdon (2000);

● evaluated the worth of the project by consulting with both Chyung (2008) and Gilbert (2007);

● consulted with the client on the importance of the project to the hospital by employing the Lean principle of the 5 Whys;

● assessed if the problem was truly a performance problem by using the questions from Harless (1987);

● located prior research into problems associated with patient transfers with hospitals (aka “handoffs”), systemic medical errors, and medical provider communications;

● adopted a structured process of data collection as recommended by Schensul and LeCompte (2013) consisting of open-ended as well as focused questions using key terms gathered from the literature, such as “handoffs” between providers or departments. (Friesen, White & Bryers, 2008). By starting with open-ended questions we identified key issues and site-specific language which we incorporated into more narrowly focused interviews and observations during subsequent stages of data gathering.

● used deductive reasoning, as per Schensul and LeCompte (2013) to synthesize the data; and

● used cost and benefit analysis, as well as consulted with the client on intervention recommendations.

The team had to adjust the plan as the team noted specific trends in the data, but by having a plan in place the team was able to focus on the data and the assessment.

Team Healthcare


Conduct the HPT process in a way that is systemic

Very early in the process, the team confirmed that the performance gap was not limited to a single person or shift of workers. For this reason, and consistent with HPT best practices, we quickly moved to study a larger context of peers, managers, processes and/or culture. Only by considering many inter-related factors in a systematic way can the root cause(s) of performance problems be found. As Tosti (n.d.) mentions, “[Determining] all the system factors that may impact the desired results [is the] KEY step in any improvement program”.

An overview of the transfer/admit process, as well as pre-existing conditions was also required since the client recently shifted from a very familiar paper-based medical chart to an Electronic Health Record (EHR). For these reasons, the team first explored the larger context of patient transfers, Electronic Health Records, and the directive that ER nurses manage the medical orders in the electronic system. The team uncovered numerous concerns related to information and incentives at the individual as well as environmental level. In other words, we uncovered evidence and possible causes of performance problems in four out of the six “cells” of the BEM.

Conduct the HPT process in a way that is consistent with established professional ethics

Team Healthcare conducted its on-site and preparatory efforts in a professional, ethical manner. We informed the client and all persons interviewed of our intentions and told all participants their involvement was voluntary. As suggested by the ISPI Code of Ethics (2002), the team masked individual identities to protect privacy as well as gather candid responses from hospital staff and managers. By doing this, the team was able to protect the client and keep their performance issues confidential.

The team requested to audit patient charts as well as observe nurses as they completed the transfer process. The audit would have allowed the team to understand what poor performance and exemplary performance would look like in the electronic record. Actually seeing the patient charts first-hand would have been optimal. Observations would have allowed the team to see nurses in action, actually performing the tasks related to transfer.

Due to HIPPA and privacy concerns voiced by the hospital staff, the team could neither collect nor see patient-specific information. Understanding that this request may put the client at risk, the team came up with alternate solutions that allowed the team to both keep the client’s trust and effectively complete the assessment. The ISPI Code of Ethics (2002) challenges professionals to show empathy for clients and their concerns; by formulating alternate solutions for our data collection, we honored this code.

Team Healthcare


Conduct the HPT process in a way that is consistent with established professional standards

Team Healthcare’s effort has met all relevant standards established by the IPSI for a Needs Assessment effort. Specifically, we have:

not accepted the initial assertion that the client had a “training problem”;

“pushed back” on the above issue and created the necessary conditions to gather data from various actors and stakeholders; and

analyzed data to uncover possible causes of performance problems that would not be solved by additional training.

Because the team pushed back, the client was able to see alternative solutions to the performance problem. Through this assessment process, the team believes it added value to the client’s organization by offering solutions to help them move to where they needs to be in the future and focus on measured performance based on proven results (ISPI, 2002, p.1).

In support of the ISPI Code of Ethics (2002), Team Healthcare set clear expectations with the client about the systematic process we planned to follow, before proceeding with the investigation of the need. The team established the following boundaries with the client:

obtained official written permission from our client to conduct our study;

agreed to keep conceal the identity of the organization and interviewees;

agreed to keep the client informed of key findings before moving to each process; and

established a professional relationship with all parties involved when collecting data.

Furthermore, one team member that previously worked for the client removed herself from the data coding and synthesis process due to her fear that she may not be able to be objective in the process. Remaining objective is directly in line with the ISPI Code of Ethics (2002).

Align performance improvement solutions with strategic organizational goals

Our findings will help the client understand that solving the performance gap will require a multi-faceted solution well-beyond “more training”. The team aimed the solutions at filling the performance gap, which will help the hospital achieve their organizational goals. The primary concern of the hospital is patient safety and providing excellent patient care. The interventions selected by the team and the client align with these goals. The team believes if the hospital implements their solutions, they will be able to preserve patient safety, avoid expensive litigation due to medical errors, which will help them also fulfill their mission of “serving the poor and underserved” by preserving their resources for such.

Make recommendations that are designed to produce valued results

Our recommendations, summarized above, reflect a “sweet spot” between the risks, costs and benefits of doing nothing, contracting for more training, or calling for elaborate, costly organization development consulting. As per Gilbert (2007), it makes no sense to spend more money fixing a problem than is gained by even the most successful intervention.

Since the cost of a single legal settlement for malpractice, wrongful death or personal injury can easily top $1M dollars, the modest costs of the team’s recommendation are clearly cost-effective and consistent with the “no resources” available to close the performance gap.

Team Healthcare


Collaborate effectively with others, in person and virtually

Team Healthcare members live in three different time zones and have collaborated across space and time by using tools such as Google hangout, Skype, conference calls, email and the Lotus Notes database.

The client and two members of the team are located in Boise Idaho. One team member is a former employee of the hospital and has acted as our single point of contact and tireless on-site representative.

The team determined that in order to verify a performance gap, it would be necessary to observe nurses in the process of a transfer. This proved logistically difficult since ER-to-Inpatient “transfers” do not happen that often. For this reason, the team prepared an observation form which the clinical educators used to make observations. This approach not only allowed the team to gather data, it built trust between the client and the team.

Communicate effectively in written, verbal, and visual forms

Team members have a diverse set of professional skills. We made deliberate efforts to couch our questions to clients in language consistent with a hospital setting, in general, and to this facility in particular.

Team members consistently interacted in ways intended to strengthen inter-team cooperation and communication.

Because only one of us was able to visit the hospital or interact with staff by telephone, the rest of us felt a duty to take on a much of the other work as possible. We kept in touch with each other via email almost daily and held conference calls at least once a week and often several times a week.

Use evidence-based practices

Team Healthcare collected mostly qualitative data from both unstructured and focused interviews and 3rd party observation. This raw data was coded and scored to enable some level of quantitative measurement of the problem space. For example, by counting key words and phrases used by respondents, we learned that the performance problem has deep roots in both the information and incentive columns of the BEM.

We employed data coding and analysis techniques recommended by Schensul and LeCompte (2013). Specifically, we collected data from interviews, 3rd party observations, and training documents, reviewed and color-coded them into BEM-based “cells”, then listed the exact words which justified each classification. We were them able to rank each of the BEM “cells” to identify those most represented tin the data gathered from various sources.

During the intervention selection, the team consulted several sources, both to guide the team in the selection process.

Team Healthcare


Contribute to the professional community of practice

If our client agrees, we will convert our project report into a “Tale from the Field” and submit it to PerformanceXpress with the hope that our efforts, however rudimentary, can help others facing similar problems.

In addition, we learned how valuable it is to gather data from multiple sources, job titles or organizational roles. Triangulation is a powerful tool that we will take our respective places of work.

We also learned how important it is to consider the cost of as intervention as well as its appropriateness. It makes no sense to spend $1 to fix a 10 cent problem!

Team Healthcare


References

Chyung, S. Y. (2008). Foundations of instructional and performance technology. Amherst, Mass: HRD

Press.

Friesen, M..A., White, S.V., and Byers, J.F. (2008) Handoffs: Implications for nurses. In Patient safety and

quality - An evidence-based handbook for nurses. Retrieved from:

http://www.ahrq.gov/professionals/cliniciansproviders/resources/nursing/resources/nurseshdb

k/index.html

Gilbert, T. (2007). The behavior engineering model. In Human competence: Engineering worthy

performance (tribute edition) (pp. 73-107). San Francisco, CA: Pfeiffer.

Harless, J. H. (1987). An analysis of front-end analysis. Performance + Instruction, 26 (2), pp. 7-9.

ISPI. (2002). Code of Ethics. Retrieved from http://www.ispi.org/pl/About/Code-of-Ethics.pdf

Langdon, D. (2000). Introduction to Performance Alignment in Business. In Aligning performance:

Improving people, systems, and organizations (pp. 1-15). San Francisco: Jossey-Bass/Pfeiffer.

LeCompte, M., & Schensul, J. (2013). Analysis from the top down. In Analyzing & interpreting

ethnographic data, 5, pp. 45-66. Walnut Creek, CA: AltaMira Press.

Marker, A. (2007). Synchronized analysis model (SAM): Linking Gilbert's behavioral engineering model

with environmental analysis model. Performance Improvement, 46(1), 26-32.

Rummler, G., & Brache, A. (1995). Viewing organizations as systems. In Improving performance: How to

manage the white space on the organization chart (pp. 5-14). San Francisco: John Wiley & Sons,

Inc.

Tosti, D. T. (n.d.). The performance engineering model. Retrieved from:

http://www.donaldtosti.com/The_performance_engineering_model.docx

http://www.ispi.org/pl/About/Code-of-Ethics.pdf

Preserving Patient Safety after the Implementation of an ......implementation. The electronic system...

Documents

Transcript of Preserving Patient Safety after the Implementation of an ......implementation. The electronic system...