Standardizing Electronic Documentation for Safe Perinatal Care

AWHONN 500-word abstract
Studies reveal communication breakdowns between providers and their patients and poor documentation, are leading causes of adverse events. In response to these alarming findings, Tenet Healthcare, one of the largest U.S. healthcare systems, engaged in an initiative to standardize documentation and transform care throughout their perinatal facilities.  The project’s goal was to reduce risk and improve patient safety in the OB/Perinatal continuum of care through adherence to evidence-based practice guidelines. The intent was to improve outcomes and reduce the spending of risk dollars.
For this presentation/research paper, Tenet‘s Perinatal Quality Director and  IBM healthcare consultant  will share the processes undertaken to standardize the design of a perinatal-specific EMR documentation system which incorporates current perinatal standards of care. The methodology involved expert perinatal clinicians, hospital and quality administrators, and technology consultants tasked with identifying opportunities to improve safety and outcomes in building the enterprise-wide standardized documentation. The team executed the following: 1) reconfigured a vendor document template; 2) identified and embedded national standards of care practices to workflow from ACOG, The Joint Commission, American Academy of Pediatrics, the Association of Women’s Health, Obstetric and Neonatal Nurses, and the National Institute of Child Health and Human Development; 3) determined policy issues; and, 4) incorporated standardized sets of OB metrics for corporate and facility analysis (this data identifies care practice outcome measures for use in continuous quality improvement, risk management and patient safety initiatives).
 Further, the project entailed an extensive review of sample clinical standards and embedded them in the EMR, including “Idealized Perinatal Care Bundles” addressing parameters for augmentation and induction of labor, SBAR Tools (Situation, Background, Assessment, Recommendation) for provider communication use in patient hand off, patient preferences for care (e.g., recognition of cultural and spiritual beliefs), screening assessment that incorporates National Patient Safety Standards related to suicide, risk factors associated with Post Partum Depression, NICHD terminology embedded in fetal monitor strip documentation, Observance of Compliance regulations (time out prior to OB surgical interventions), transforming work flow processes to hardwire EMATALA requirements during the Triage phase, and improved communication regarding fetal surveillance.
In a unique move, the team consulted ancillary and financial department personnel who used gap analysis techniques to develop a perinatal care transformation driving hospital-wide process improvement.  Challenges encountered helped strengthen the end result.  Among them, standardization is recognized as a time-consuming and tedious process, and entails a cost investment in convening multiple hospital teams and the EMR vendor. A significant commitment from facilities to support participating clinicians is not always evident.  Several lessons were learned including:  Enlisting system end users creates buy-in and sets the stage for rapid adoption; involve physicians early and often in the process; and recognize the importance of the system [that is, a change in one part of the system creates a change in the whole system] by engaging all ancillary departments and recognizing their impact in a successful conversion to perinatal electronic documentation.