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					Nursing and Clinical Informatics: Project Management, Application Support and Beyond

The Miriam Hospital 3/14/06

Decision making must be based on the use of accurate information
Florence Nightingale 1850

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The Environment The Miriam Hospital
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Projects and Creating Value

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Forward to the Bedside!

Trends in our Environment

Top Business Issues Facing Healthcare
CIO
1.
2. 3. 4. 5. 6. 7. 8. 9.

CEO
1. 2. 3. 4. 5. 6. 7. 8.

CNO/CMO
1. 2. 3. 4. 5. 6. 7. 8.

Reducing Medical Errors
Patient (Customer) Satisfaction Improving Quality of Care Improving Operational efficiency Cost Pressures Clinical Transformation Medicare Cutbacks HIPAA Compliance Adoption of New Technology

Medicare Cutbacks Operational efficiency Cost Pressures Increasing patient Safety Patient Satisfaction Quality of Care Nursing Shortage Obtaining Capital

Increasing Patient Safety / Reducing Medical Errors Patient (customer) Satisfaction Nursing Shortage Cost Pressures Medicare Cutbacks Improve Quality of Care Clinical Transformation Facilities Upgrades

16th Annual HIMSS (2005) Leadership Survey Sponsored by Superior Consultant Company/ ACS Healthcare Solutions

The Miriam Hospital
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The Miriam Hospital (TMH) is a private 247-bed, not-for-profit, acute care general hospital founded by Rhode Island's Jewish community in 1926. The Miriam provides a broad range of primary, secondary and tertiary medical and surgical services to adolescents and adults in 33 medical and surgical specialties and sub-specialties. In addition, TMH provides a full range of cardiac, pathology and radiology services as well as psychiatric consultation/liaison services. The Miriam’s leading service line, measured by volume and profitability is cardiac. Oncology, orthopedic surgery and immunology are also significant service lines. TMH is affiliated with and serves as a major teaching affiliate of Brown Medical School. The Miriam was the ninth hospital to be awarded ANCC Magnet Recognition and the first to achieve it in New England.

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What is Clinical Informatics / IT here at TMH?

Life span

TMH

RIH

NH

Rebecca Burke

Jane Metzger

Denise Dorato

Mary Kennedy RN Dir, Clinical Informatics Martha Carnes RN Nursing Information Specilialist

Sue Whetstone RN Nursing Informatics Mgr Danise Davis RN Nursing InformationSpecialist

Valerie Martin Dir., Surgical Nursing

Dept. of Clinical Informatics
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Services _ Tactical Planning/ Project definition _ Project Management/ Implementation
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Project Planning Workflow analysis/ requirements definition Software testing Training / Documentation

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Clinical System Support & Problem Resolution

Dept. of Nursing & Applications
Major Projects within the last 2 years _ Medication Safety
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CPOE ( POM:Physician Order Management) On-line med charting ( 2006 May pilot)

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Intraoperative Scheduling , resource management and documentation Enhanced Bed Management
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Phase I implementation (3/06)

Medication Safety

Medication Safety
Siemens Pharmacy

CPOE/Pharmacy Interface

Siemens MAK

CPOE live

1st

unit Pharmacy/Lab Interface

CPOE live all inpatients

Apr 02

Jul 02

Mar 03

Jun 04

Oct 04

FY 06

CPOE (POM)Value @ TMH
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“CPOE (POM) Logic” prevented errors:
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Incomplete/unclear orders (down 69%) Excessive dose (down 47%) Therapeutic duplicates (down 7%)

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Average Turn Around Time
90 to 8.5 minutes and 96% of orders verified in 30 minutes or less Medication Removals by Pyxis Override reduced by 51,000 doses/year 93% of Net Pharmacy orders ordered by Physicians
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Medication Administration Charting

Online Med Administration Implementation
The next logical step towards error reduction

Monitor ing Dispensing 2% 3% Pr escr ibing 8%

Prescribing Administration Transcription Dispensing Monitoring

41 263 191 12 14 521

8% 50% 37% 2% 3%

Tr anscr iption 37%

Actual Errors Potentially Impacted : 87%
Source: RIH/TMH actual error data FY05 (10/04-3/05)

Administr ation 50%

Medication Administration Charting

Intraoperative
Case scheduling, resource management, doctor preference card management, and charting system

Bed Management
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Benefits
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Improved accuracy of unit based / hospital census; Streamlined communication as evidenced by decrease manual processes (i.e. fewer faxes, phone calls) Timeliness of patient placement through real time automation (i.e. From the time a bed request is opened to the time that a patient is actually in a bed on a patient care unit) Access to real time information at the patient care unit

Creating Value

How does or can informatics create value for Nurses and the delivery of Patient Care?

Vc = Q/C
Value (customer) = Quality/ Cost

Department of Clinical Informatics
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Creating Value
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Order set Maintenance
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Expanding into Special Procedure Areas Including CNS consults

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Implemented Genesis orders on-line with supporting care management tools (Slips/ Falls) Payor / Level of Care order management initiative Through-put /Surge capacity management initiative Downtime Communication initiative Multiple Patient ID and order management initiative

Department of Clinical Informatics
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Nurse Noted (On-line Order Acknowledgement) Audit Tool
Orders w ithout NN (Total) 5000 4597 4500 4000 3500 3000 2500 2000 1500 1000 500 0 Totals 1311 1121 1026 1023 1104 815 2743 2529 3905 07/16/05 07/23/05 7/30/2005 8/8/2005 8/13/2005 8/20/2005 8/29/2005 9/3/2005 9/10/2005 9/17/2005

Department of Clinical Informatics
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(Patient ID) Glumeter /Scanning Patient ID initiative

Blue = Total Scanned, Rose = Total performed
18000 16000 14000 12000 10000 8000 6000 4000 2000 0 Feb March April May June July August Sept Oct

Department of Clinical Informatics
Improved Compliance _ Removed all “Do Not Use” abbreviations from POM Process Improvements/ Value Added _ Re-designed access to and actual policy and procedure page _ Enhanced midnight census report to include patient condition for better reporting; _ Redesigned dietary report Risk Management/ Intense Analysis participation _ All POM occurrences sent to department and included in all POM related intense analysis

Department of Clinical Informatics
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Research/ Publication - 2005
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The Impact of Health Information Technology (HIT) on the Role of Nurses and Interdisciplinary Communication in Acute Care Settings Surveying Acute Care Providers in the U.S. to Explore the Impact of HIT on the Role of Nurses and Interdisciplinary Communication in Acute Care Settings - Submitted and accepted (JHIM)

Next Year!

This Year!
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Affiliate Based Projects
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Project management
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Ongoing Projects
New Major projects New „Minor‟ projects

Forward to the Bedside!

This year!
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NEC
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Nursing Infrastructure
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Creating the Value Proposition (conceptual to execution) Clear, well defined and aligned strategic direction
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ISSSC communication TMH IS Council structure Service request reconciliation Project Introduction Project communication

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Project Management focus (MIS 001)
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Communication (Web page and e-mail) SW Project Management & Informatics Literacy HW evaluation / acquisition

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Nursing / Patient Care Services Department
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Create Nursing Informatics Committee Informatics Competencies Begin Clinical Doc Standardization Process

TMH Nursing Council – The Vision
Nursing Executive Council
Nursing Quality Council

Unit Council Steering Committee

Nursing Safety Council

Direct Care Staff

Unit Councils
• ICU •CCU •CVT •3W •3E •3B •4E •4W •ED

Evidence-Based Practice Council Clinical Informatics Council Professional Development Council Nursing Leadership Council

Patients

Hospital Environment

Clinical Informatics Council
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Purpose:
The purpose of the Nursing Informatics Council is to advance the nursing care of patients and promote professional nursing development by managing and processing nursing data, information, and knowledge

Clinical Informatics Council
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Objectives :
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Provide leadership in the specialty of Nursing Informatics. Recommend IT competencies for Nursing staff Identify knowledge needs of nursing staff related to the management of information and the implementation of new technology Collaborate with other health care disciplines to create an integrated clinical information system. Encourage the development of strategies that support clinical decision making and facilitate data entry and retrieval Look for the best in research and practice to continuously improve Nursing practice through the use of technology

Clinical Informatics Council
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Membership:
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Membership shall consist of at least 12 members with representation from each patient care unit/ site with in Nursing Services - all shifts and all specialty areas. Members will be requested from specific units or specific nursing care areas as needed for implementation of special projects on an ad hoc basis.

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Reporting:
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The committee Chairperson will report on a regular basis to the Director of Clinical Informatics as well as on an ad hoc basis to NEC. An annual report will be made to the NEC as requested by the Vice President for Nursing.

Developing Informatics Competencies

The Vision
“Previous work primarily has focused on computer-related skills, rather than examining a broad definition of informatics competencies. For this current work, NI competencies encompass all skills, not only computer-related skills, as well as knowledge and attitudes needed by nurses.”
PhD, Nancy Staggers RN, FAAN; Gassert, Carole A. PhD, RN, FAAN; PhD, Christine Curran RN, CNA Informatics Competencies for Nurses at Four Levels of Practice. Journal of Nursing Education. 40(7):303-316, October 2001.

PhD, Nancy Staggers RN, FAAN; Gassert, Carole A. PhD, RN, FAAN; PhD, Christine Curran RN, CNA Informatics Competencies for Nurses at Four Levels of Practice. Journal of Nursing Education. 40(7):303-316, October 2001.

Today‟s Environment

Introducing informatics competencies into the bedside culture

POM Nursing Evaluation YTD '05 N=80
4.0 3.5 3.0 2.5 2.0 1.5
Q1 Relative to my needs, the ideas and concepts of this program w ere appropriate

1.0

Q2 The speaker communicated in such a w ay that I found it easy to follow and comprehend each idea presented Speaker A: MARTHA CARNES 1 Speaker B: PAM WATERMAN Q3 - The objectives established for this program w ere met Objective #1 Learner w ill demonstrate how to look up lab results in Nurse Links Objective #2 Learner w ill demonstrate how to look up diagnostic test results in Nurse Links Objective #3 Learner w ill demonstrate how to check availability of blood products in Nurse Links Objective #4 Learner w ill demonstrate how to enter height, w eight, and allergies Objective #5 Learner w ill demonstrate how to enter orders for medication, both IV and PO Objective #6 - Learner w ill demonstrate how to enter Laboratory orders Objective #7 - Learner w ill demonstrate how to enter Radiology orders Objective #8 - Learner w ill demonstrate how to enter Respiratory Therapy orders Objective #9 - Learner w ill demonstrate how to enter Patient Care orders Objective #10 - Learner w ill demonstrate how to enter Diet orders Objective #11 - Learner w ill demonstrate how to sign orders using passw ord Objective #12 - Learner w ill demonstrate how to revise Pharmacy and non Pharmacy orders Objective #13 - Learner w ill demonstrate how to verify an order Objective #14 - Learner w ill demonstrate the w orkflow process: order session prints, medication labels Objective #15 - Learner w ill demonstrate how to note nurse orders including discontinued orders using 24 hour tab

Our needs
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A systematic approach to maintaining competency is not in place Room to improve
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Application Knowledge
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Intranet Patient links / Nurselinks
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ADT functions Results POM

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Data access/ Practice areas
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Ht & Wt, Allergies, Precautions Protocols (Heparin) Blood Availability Respiratory Charting Entering POM orders ( Meds, PTT, Diet with modifiers, consult) Nurse Noted Re-generating reports and labels

The Proposal
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Develop a new educational structure to help guide nurses in learning
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New Hire Orientation Maintenance of Competencies

Experiential Learning Framework

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Learning occurs when knowledge is grasped
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(I.e., learned, received, exposed to, etc.) (i.e., made meaningful, incorporated into current knowledge and practices, etc.)

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And then transformed
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Moving Toward Change
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Resources are currently in place, but need to be modified to fit new framework

This year ! (cont’d)
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Clinical Informatics Dept.priorities
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System Support Administrator (POM, MAK, iPath…) Project Management* Support for Affiliate Initiatives
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JCAHO: Core Measures & NPSG Patient Safety : Leapfrog

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Clinical System, Practice and Management integration

If we don't change direction soon, we'll end up where we're going.
Professor Irwin Corey American vaudeville comic and actor (1914 - )

Discussion
Mary K. Kennedy RN, MS (mkennedy@Lifespan.org) Dir., Clinical Informatics The Miriam Hospital 164 Summit Avenue Providence, Rhode Island 02906


				
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