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CPM Resource Center

Built to address the root causes of the safety problem – fragmented health care infrastructuresand unhealthy work cultures – IDA supports the practice and workflow of practitioners at thepoint of service.

A 1999 Institute of Medicine (IOM) study pointed out the frequency and severity of adverse medical events, bringing to the forefront the need for safer patient care. Subsequent recommendations from the IOM and patient safety advocacy groups have heightened the debate. President Bush underscored the issue in his 2004 State of the Union address when he called attention to computerizing health records to address medical errors.

The issue of safety is just as much about the safety of those giving care as it is about those receiving it. At the root of this need for improved safety is the importance of creating a healthy environment that fosters safe practice and safe care. A key building block in this transformation is intentionally designed automation (IDA). This innovative approach plays a significant role in renovating the work culture and infrastructure of health care organizations worldwide.

Steps Toward Creating a Healthy, Healing Work Culture

The stress experienced by health care professionals in today’s work culture is unprecedented. The root of this stress comes from the gap between the deeply held personal desire to give safe, individualized, quality care and the lack of ability and support to deliver such care. The desire to provide care excellence and touch the lives of patients is met with challenges of increased workloads, staff shortages, fiscal constraints, inadequate tools and resources, stressful relationships, and growing regulatory concerns. Such an environment clouds the caregiver’s connection to the reason that she chose the profession in the first place. This frustrating work culture impacts patient and caregiver satisfaction as well as patient and staff safety.

Automation is at the center stage to help decrease errors and support safe, quality care. It brings the potential to enhance every step of cultural transformation necessary to create the best places to work and receive care. To achieve this requires IDA built to address the root causes of the safety problem – unhealthy work cultures and fragmented health care infrastructures. IDA functions as a partner with clinicians to facilitate and equalize the delivery of care. This, in turn, empowers clinicians to provide the necessary human contact required for healing.

For over two decades, the Clinical Practice Model Resource Center (CPMRC) has sought the wisdom of thousands of health care colleagues and patients to determine the fundamental elements that create and sustain cultures that assure quality, safety, and satisfaction. CPMRC designed a system around a professional practice framework that supports the practice and workflow of all practitioners at the point of service. Deploying technology as a means to augment a healthy, healing work culture requires more than automating paper-based processes. It requires IDA that builds intuitive support for each step of professional practice, which is driven by an integrated, interdisciplinary vision for evidence-based practice.1 When evidence-based treatment guidelines are also automated, it provides key benefits to payers, who view these tools as a means to standardize treatment, increase efficiency, and control costs.

CPMRC has published multiple articles detailing the requirements to sustain a healthy, healing work culture and integrated care at the point of service.2 These articles present the use of the molecule as a metaphor for the fundamental elements that are present in a healthy culture. For a molecule to exist as matter, every atom comprising the unique structure of that molecule must be present. For example, a water molecule requires two hydrogen atoms and one oxygen atom (H2O). If you remove a hydrogen atom from the H20 molecule, it is no longer water. The fundamental elements required to sustain a healthy healing work culture and integrated care are arranged as a molecule in Figure 1.

Figure 1. Healthy Work Culture Molecule Metaphor

Each of the elements correlate with an IOM recommendation3 and support the transformation work required for creating the best places to work and receive care.

Expecting More Than the Obvious

Today’s health care information technology vendors uniformly promote the ability to prevent medical errors with the aid of technology. This is one of the obvious requirements for an automated system. Other obvious benefits include eliminating the need to read or decipher handwriting or locate paper charts and test results; reducing phone calls and paper costs; and increasing the ability to retrieve data and objective reports.

Equally important are the less obvious requirements. These address the long-standing stressors and realities that affect practitioners daily. Some of the less obvious expectations relate to respect, collegiality, competency/ adequacy, continuous learning needs, individualized care, integrated interdisciplinary care, scope of practice support, evidence- based care, and daily communication. Such requirements can only be addressed through IDA.

The clinical realities expressed by clinicians throughout this article give insights into the need for IDA to consciously address the less obvious requirements. These statements reflect the fundamental issues that take place daily, creating stress and diminishing a caregiver’s passion and success as a healer.

Clinical Reality

“After I was given reports on my patients, I realized that I had just spent 40 minutes with a peer who informed me of each patient’s diagnosis, the physician’s orders, and completed and pending treatments. However, I had no idea who the patients were under all of it. It is as if it doesn’t matter anymore who they are. I went back to the chart and couldn’t find the patient’s story anywhere. We have dehumanized our relationships with each other and the patients.” (Nurse, Wisconsin)

IDA: Respect, Safety, and Humanization

At the heart of a healthy, healing work culture is respect – for patient and caregivers alike. IDA not only enhances relationships but gives the clinician more time to be in relationships with other caregivers and patients.

Fred Patterson, M.D., consultant for H2O Resources Group, has found that “Changing the culture of work within the health care setting is possible, and getting the relationships right is the first step. Moreover, obtaining organizational and strategic buy-in is an essential step in moving clinicians, and especially physicians, along in their ability to accept large-scale change – an important facet of any cultural transformation. Interestingly, this helps improve clinician satisfaction as well.”

How Does IDA Impact Respect, Safety, And Humanization for the Patient?

It captures the person’s unique story and presents it to others as a blueprint from which individualized care can be designed; and

It alerts those who give care to ensure that their actions are appropriate for each patient.

How Does IDA Impact the Respect, Safety, and Humanization of Clinicians?

• It simplifies the high-level professional assessment/intervention process of capturing the patient’s story accurately;
• It serves as a central communication tool among all caregivers;
• It accurately displays services provided to the patient and helps all colleagues plan and integrate their unique service;
• It provides an accurate summary of the patient’s story, a reflection of who they are in body, mind, and spirit, to every clinician who enters their room;
• It facilitates each clinician’s ability to save and retrieve the story in one place;
• It highlights unique information to help prioritize and save time; and
• It presents the patient’s story in both words and pictures indicating who they are (eventually, it will include the patient’s actual voice), what is important to them, and what they need from the caregiver.

With these capabilities, a complete information set is immediately available to each clinician, eliminating fragmentation and dehumanization. Information can be used to build and deepen relationships with peers and patients. Technology becomes a means to achieve high touch and individualized care, which Koerner4 refers to when she notes “What most nurses mourn is the minimization of the relationship side of caring, that sacred space where astute observation of slight change and timely intervention can make a significant difference in the illness trajectory of the patient.” This is true for the whole health care team.

Clinical Reality:

• “I was the primary caregiver for a woman who was not doing well and there were more questions than answers. There was a stream of people caring for her. It was almost as if they tried to slip in and out without being noticed, too busy to take time to talk about her care. I was trying to coordinate her care, yet I had to track people down. It was as if I was invisible. (Nurse, New York)
• “We all do our own thing, under our own tab in the chart and no one has time to read what anyone else wrote.” (Dietician, North Dakota)
• “It only seems to matter that the forms are filled in. It doesn’t seem to matter that the forms are filled in with useless information that doesn’t help us care for patients.” (Nurse, British Columbia, Canada) • “I spent 30 minutes assessing the patient and finding out his concerns and charting what he told me only to hear that he already conveyed the same information to the therapist.” (Nurse, Michigan)

IDA: Scope of Practice

IDA begins with clarity on the scope of practice. The 1999 IOM report notes “Inconsistencies are exacerbated by variation in the scope of practice” as well as the care venue. Fortunately, an integrated, interdisciplinary approach to care that clearly defines scope of practice/service can eliminate inconsistencies in care delivery. With a clear definition of each discipline’s scope of practice across the organization, the entire team is empowered to deliver the best care possible and improve outcomes. Within this framework, each member of the team understands the scope of practice and expertise of every other team member and all are individually accountable to their discipline and to the team, creating truly interdisciplinary care.

IDA based on scope of practice shifts automation design from the obvious task list mindset which perpetuates institutional practice to an integrated professional practice workflow. This stops duplication of services and focuses the team on collective accountability to the individual’s plan of care. When there is clarity on scope of practice, automation can be brought to a higher level of support for the clinicians. Why? Automation can bring preconfigured evidence-based content and tools to each discipline to enhance its scope. This innovation transforms the structure, process, and outcomes of practice. IDA based on scope of practice demands a unique behind-the-scenes functionality very different from the obvious task list requirements. It requires integration of professional services, technology, and evidence-based content into an intuitive design that:

• Creates an expectation of interdisciplinary service integration;
• Automatically embeds scope of practice accountability into daily documentation;
• Alerts providers when inconsistency of evidence-based observation and interventions occur;
• By integrating data it breaks the silo practice patterns which cause fragmentation;
• Alerts colleagues in real time that consultation/conversation is needed in today’s care;
• Summarizes critical scope of practice data, not a list of check boxes;
• Stops duplication of services, repetition of assessment, charting, reporting, and education of clients and families; and
• Enhances partnership and confidence with both professional colleagues and clients, enhancing satisfaction for both those who give and receive care.

IDA based on scope of practice helps create an environment where together, the nurse, pharmacist, respiratory therapist, physician, and the clinical information system are partners responsible for ensuring the safety of patients and staff. This is a major stepping stone on the path to care excellence, enhancing both clinician’s lives and patient health. “It is within this configuration that a synergy within the team and between technology and the delivery of care occurs,” notes Robert Kuramoto, M.D., managing partner of Quick Leonard Kieffer International, an executive search firm for health care leadership, and a practicing surgeon. “Relationships improve, individual expertise is maximized, dialogue becomes an integral component within treatment planning, and patient and staff satisfaction is enhanced.”

Clinical Reality:

• “Do you know what it is like to feel that you do not know enough to give the patient the kind of care he or she deserves and there is no one to turn to for questions, to learn from, or to help you?” (Practitioner, Wisconsin)
• “I had to act without adequate information because of the patient’s acuity. All night long I worried about whether I had done the right thing. When I got home, I could not go to sleep, worrying about the safety of the patient. I was afraid that I had missed something important and would repeat those mistakes in the future.” (Nurse)5

IDA: Evidence-Based Care

The focus on patient safety is another way to bring forward the guiding principle from Hippocrates, “Above all, do no harm.” That desire resides in the hearts and minds of every clinician. In its simplest form is a call to actively prevent complications for which the patient is at risk and to recognize the insidious symptoms of complications that can occur. In today’s health care environment, a shift from task-dominated practice to evidencebased practice is necessary for clinicians to continue to fulfill the tenet of the Hippocratic Oath.

Sackett, Strauss, Richardson, Rosenberg, and Haynes6 define evidence-based practice as “The integration of best research evidence with clinical expertise and patient values.” Evidence-based practice proposes to support the key quality indicators of competency, safety, consistency of care, and individualization of care. Because omissions in care are less likely to occur with evidence-based decision making, there is a direct correlation to improved patient safety.

IDA supports clinicians in a variety of ways. It brings evidence- based information to clinicians when and where they need it. For example, if a clinician is caring for a patient with a diagnosis that he is unfamiliar with, such as Guillain-Barre, the clinician may not be aware that a major complication for this condition is Autonomic Nervous System Dysfunction. The nurse should know the signs/symptoms and appropriate preventative interventions necessary to minimize the patient’s risk for such complications. If the clinician does not have this understanding (evidence) from the literature, some interventions may not be carried out. These omissions unknowingly increase the risk for complications. Missing the potential complications and the subsequent preventative interventions are what cause nurses and other disciplines to fail to rescue patients from predictable undesired outcomes.

In this example, IDA:

• Brings the Guillain-Barre evidence-based clinical practice guideline to caregivers’ fingertips in a concise and brief format, with critical data highlighted. These include: common outcomes, complications, signs and symptoms, and preventative interventions.
• Behind the scenes it automatically creates a flow sheet and education record with cues to support the delivery of such care;
• Provides alerts regarding symptoms of complications;
• Provides real-time communication among caregivers and helps them focus on an integrated plan of care, where each clinician can build upon the other’s expertise;
• Provides general information related to the definition, common treatments, and explanation of pathophysiology if needed; and
• Decreases the stress of not knowing and being alone.

With clinical practice guidelines providing key assessment skills and information to help the nurse recognize common complications of this disease, the nurse can deliver the best care possible. This optimizes the nurse’s ability to practice independently as well as interdependently with the health care team. It also improves the nurse’s ability to use her intellect to treat patients. In turn, having this information available reduces stress and increases job satisfaction.

A Shared Vision for Integrated, Evidence-Based Care at the Point of Service

CPMRC has collaborated to develop knowledge-based charting (KBC), an automated version of its clinical methodology. This methodology is incorporated into the advanced clinical solutions developed by Eclipsys, a health care software and services provider. Designed from the concept of supporting the intuitive process of clinicians and removing barriers to workflow, KBC provides realtime access to and content integration of over 180 evidence-based clinical practice guidelines into a pre-configured, interdisciplinary documentation system that meets the professional standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Magnet recommendations.

Eclipsys and CPMRC are dedicated to bringing evidencebased knowledge to all health care professionals at the point of service through IDA. Eclipsys is also committed to delivering the most comprehensive clinical content available through its advanced clinical software solutions.

Clinical Reality

“You can’t imagine how tense it is in our operating room. No one would be this rude, impatient, disrespectful, or unkind to people on the streets and yet we live like this every day … and we are supposed to be the healers.” (Nurse, California)

The critical mission of IDA is captured in the statement above. It seemed appropriate to end this article by underscoring the importance of intentionally designing a tool that will serve our colleagues, the healers of this humanity. We can and must decrease as many stressors as possible and support clinicians in their daily work. The IOM called for “healing relationships” as one of the significant actions needed to assure safe environments. CPMRC, with the help of thousands of clinicians and patients, established a partnership infrastructure that brings together the interdisciplinary team to perform the work required to sustain healthy, healing work cultures and integrated care.7 IDA took root from the wisdom of these partnership councils.

Hospitals implementing the CPMRC framework report numerous positive outcomes. These include improved recruitment and retention, better compliance with regulatory standards such as JCAHO, increased patient and staff satisfaction, streamlined workflow, reduced duplication, improved relationships within interdisciplinary teams, and standardization of care across all venues.8

When practitioners log on to automation that is intentionally designed, they are reminded that they are on sacred ground. They have access to the fingerprints of the lives of those who give and receive care. The screens are filled with real pictures that are full of the miracles and the challenges of life. They are never alone. They have in their hands a powerful high-tech, high-touch partner. In this way, IDA is a powerful tool that decreases stress and helps sustain cultures that are the best places to work and receive care.

Endnotes

1 C. Belmont, B. Wesorick, H. Jesse, M. Troseth, and D. Brown, “Clinical Documentation,” HCT Project, 2003.

2 B. Wesorick, “21st Century Leadership Challenge: Creating and Sustaining Healthy Work Cultures and Integrated Service at the Point of Care,” Nursing Administration Quarterly, Vol. 26, No. 5 (2002): 18-32; K. Grigsby, D. Westmoreland, L. Shiparski, “Capacity Building of Leaders in Healthcare Organizations,” Journal of Nursing Administration, Vol. 32, No 7/8 (2002): 398-404.

3 Committee on quality of health care in America – Institute of Medicine, “Crossing the Quality Chasm: A New Health System for the 21st Century,” Washington, D.C.: National Academy Press, 2001.

4 J. Koerner, “Nursing: the Canary in Healthcare” Nurse Leader, Vol. 2, Issue 1, 2004: 23-27.

5 J. Koerner, “Nursing: the Canary in Healthcare” Nurse Leader, Vol. 2, Issue 1, 2004: 23.

6 D. Sackett, D. Strauss, W. Richardson, W. Rosenberg, and R. Haynes, “Evidence- Based Medicine: How to Practice and Teach EBM,” London: Churchill Livingstone, 2000.

7 B. Wesorick, L. Shiparski, M. Troseth, and K. Wyngarden, “CPMRC Partnership Infrastructure Fieldbook: Strategies And Tools For Co-Creating A Healthy Work Place,” Practice Field Publishing, 1998.

8 K. Grigsby, D. Westmoreland, and L. Shiparski, “Capacity Building of Leaders in Healthcare Organizations,” Journal of Nursing Administration, Vol. 32, No 7/8 2002: 398-404.