Empowering Nurses to Improve Patient Care: Technology and Standardization of Documentation
Until recently, perinatal nurses at a health system documented multiple times the same information onto a patient’s paper chart, increasing the risk of incomplete data handed over to nurses undertaking the next shift. The lack of uniformity in the different chart formats, forms and terminologies used across three hospitals in the care management of obstetric patients posed serious risks due to variations in care delivery.
In 2003, the not-for-profit health system replaced manual documentation processes with an evidence- and standards-based perinatal documentation system to improve patient safety, data integrity and consistency, and efficiencies. The centralized system would accomplish two goals: 1) automate documentation that met standards of care practices from the Association of Women’s Health, Obstetric and Neonatal Nurses, American College of Obstetricians and Gynecologists, and American Academy of Pediatrics, and 2) collect data to comply with perinatal requirements from the Joint Commission and state Board of Medical Quality Assurance.
The health system implemented the electronic perinatal documentation system at two hospitals and will conclude deployment when a third facility goes paperlight in January  2009, raising the level system-wide in patient safety, outcomes, efficiencies, and adherence to standardized practices.  By Feb. 1, 2009, 950 nurses will be documenting at the bedside, up from 450.
The speaker will present the following case-study challenges and lessons learned:
·        Understand the importance of empowering nurses to lead the design and selection of an enterprise-wide documentation system as well as the effort to “harmonize” perinatal clinical and business practices across three facilities.
·        Institute creative methods to educate nurses without interruption to patient care.
·        Identify pitfalls and peaks lessons learned in the standardization process.
·        Realize that standardization is ongoing as evidence and standards improve.
Today, the health system is realizing significant savings which are expected to increase as the organization moves to next phase—integrating barcode medication with the obstetric and nursing documentation system.
The presentation concludes summarizing the nursing benefits--illustrated with real-life examples--gained through standardized perinatal documentation:
·        Development of comprehensive treatment plans that ultimately lead to improved quality and outcomes. Data is entered only once and is immediately accessible.
·        Higher job satisfaction due to work/life balance and spending more time with patients. Previously, nurses unable to complete documentation during regular work hours averaged 20 minutes overtime or 60-90 minutes overtime if documenting on paper.  Charting a new admission is reduced 50 percent.
·        Efficient allocation of nursing resources.
·        Significant reductions in paper forms.
·        Compliance with Joint Commission’s patient safety goals.