Building Capacity: Achieving Quality Improvement through a Systems Approach to Nursing Documentation Isabelle Mogck Chief Nursing Officer Director of Communicable Diseases Co-authors: Rebecca Spark - Research and Policy Analyst Dale Clarke Supervisor 1
Peel Where Are We? West of Toronto 1.3 million residents (20,000 people added each year) Toronto International Airport
Overview Chief Nursing Officer Initiative Documentation Context Rapid Review Recommendations The Documentation System Change Management Strategies Baseline Evaluation Results Next Steps 3
Why Documentation and Why Now? Chief Nursing Officer responsible for leadership in nursing, continuous quality improvement, & organizational effectiveness Inconsistencies in documentation creates risk mitigation and quality assurance concerns Plan for electronic client record Efficient and effective documentation will be understood and practiced by all nurses as an integral part of nursing practice and a valuable tool for ensuring quality client outcomes.
Documentation Context Situational Assessment: PPH Legislative requirements, professional standards, organizational polices Multiple databases, systems, frameworks, policies, procedures, & guidelines 18 programs Consulted similar health units 5
Rapid Review What are the essential elements of nursing documentation to mitigate risk as defined by better client, nurse, and organizational outcomes?
Rapid Review Key Findings High quality evidence: Suggests clinical pathways and structured forms can have positive effects on patient outcomes and computerized records may not. Demonstrates that clinical pathways and structured documentation can have positive impacts on organizational outcomes. Qualitative evidence: Provides essential elements of high quality nursing documentation that can be incorporated into policies, procedures, and guidelines.
Rapid Review Recommendations 1. Create policies and procedures 2. Implement clinical pathways or structured documentation (e.g., flow sheets, care plans) 3. Develop measures and collect baseline data 4. Monitor and evaluate 8
Purposes of Documentation To reflect client perspective, clear, accurate, timely To communicate to all health care providers the plan, assessment, interventions and the effectiveness of interventions To demonstrate that the nurse has applied, within the therapeutic nurse-client relationship, the nursing knowledge, skill and judgment required (College of Nurses of Ontario, 2009) 9
System Supports 1. Standards (e.g., College of Nurses, Ontario Standards) 2. Organization Policies and Procedures / Forms / Databases 10
New Documentation System Components 1. Charting by Exception 2. Focus Charting 11
What is Charting by Exception? (CBE) Clearly written norms and standards Procedures for actions specific to client Structured forms 12
Focus Charting = Structured Narrative Notes Narrative documentation by exception: - differs from norm - new information - nursing judgment - minimal 13
1. Focus Statement 2. Data (D) The 4 Key Elements of a Focus Note 3. Action (A) 4. Response (R) 14
Managing Change Kotter s Eight-Stage Strategy Resources: Facilitators Guide for Management Staff Resource Guide for Nursing Staff (Kotter, J.P. (2012). Leading change. Harvard Business Review Press.) 15
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Documentation System Resources Nursing Documentation System Overview Facilitators Guide for Management Staff Resource Guide for Nursing Staff to implement the new system 17
Performance Measurement Evaluation Objective: to develop an effective and efficient system for nursing documentation Effective Documentation: includes the essential elements of high quality nursing documentation Efficient Documentation: uses the minimum time required to be effective 18
Evaluation We needed measures to assess progress toward objectives: Time spent documenting Late entries Efficiency Supporting materials Number of places for documentation Effectiveness 19
Key Structure & Process Components Vision / Policy & Procedure Rapid Review / Knowledge Translation Implementation Evaluation / Audit System Change Management Strategy / Education 20
System Enablers for Change Clear guiding vision Support from Senior Management Communication strategies needed Use existing committee structure with role clarity for support and feedback Resources, methods, tools 21
Next Steps? Full implementation by December 15, 2015 Ongoing assessment & evaluation Evaluate metrics against baseline of 2015 Future EMR 22
Selected References Clarke, D., & Spark, R. (2014). Essential elements of nursing documentation: A rapid review. http://www.peelregion.ca/health/library/pdf/essen-elem-nursing-docu-rapid-review.pdf College of Nurses of Ontario. (2009). Documentation, Revised 2008. http://www.cno.org/global/docs/prac/41001_documentation.pdf College of Nurses of Ontario. (2009). Therapeutic nurse-client relationship, Revised 2006. http://www.cno.org/global/docs/prac/41033_therapeutic.pdf College of Registered Nurses of British Columbia. (2013). Nursing documentation. https://www.crnbc.ca/standards/lists/standardresources/151nursingdocumentation.pdf. Jefferies, D., Johnson, M., & Griffiths, R. (2010). A meta-study of the essentials of quality nursing documentation. International Journal of Nursing Practice, 16: 112-124. doi:10.1111/j.1440-172x.2009.01815.x Ministry of Health and Long-Term Care. (various dates). The Ontario Standards. http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/ophsprotocols.aspx Rotter, T., Kinsman, L., James, E.L., Machotta, A., Gothe, H., Willis, J., Snow, P., & Kugler, J. (2010). Clinical pathways: Effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database of Systematic Reviews, 3. Art.No.:CD006632. DOI: 10.1002/14651858.CD006632.pub2 Urquhart, C., Currell, R., Grant, M.J., & Hardiker, N.R. (2009). Nursing record systems: Effects on nursing practice and healthcare outcomes. Cochrane Database of Systematic Reviews, 1. Art. No.: CD002099. DOI: 10.1002/14651858.CD002099.pub2 23
Thank you CPHA Vancouver Contact Information: Isabelle Mogck, RN, BScN, MEd,CHE isabelle.mogck@peelregion.ca 24