Clinical Documentation System

Introduction

The introduction of a clinical documentation system in healthcare is carried out with the aim to improve the quality of care and make the work process a lot easier for the staff. The clinical documentation system is aimed at ensuring that the patient data is safer and readily available for use (Hamilton, 2009). In some cases, despite these known benefits of clinical documentation, the system implementation can lead to failure due to lack of adequate preparatory measures. This case study aims to review the issues that have led to the failure of the clinical documentation system in Garrison Children’s Hospital. The case study will review the available alternative that can be used to reverse the current situation and make recommendations on the implementation process. 

Inhealth record system

Background

Garrison Children’s Hospital, a 225-bed hospital, offers a wide array of services including a neonatal intensive care unit (NICU) for the premature and critically ill neonates. Other services offered include the pediatric intensive care unit (PICU) that provides care for critically ill children starting from birth to those who are eighteen years of age. The hospital is part of the Premier Health Care which is an academic center that includes an adult hospital, a psychiatric hospital along with adult and pediatric outpatient clinic. The Premier implemented an electronic clinical documentation system in the adult hospital in a period of six months. The Garrison Children’s Hospital implemented the same system in both its pediatric and surgery units as well as the intensive care units with the electronic scheduling implementation to follow soon. 

The implementation of the clinical documentation system led to a host of issues arising which has hindered the Garrison Children’s Hospital from benefiting from the system. The nursing staff have expressed concerns and dissatisfaction with the new clinical documentation system but have failed to raise the issues with the chief nursing officer. Main of the nursing staff concerns is based on their feeling that the “flow sheets” that are available in the new system are inadequate and could end up compromising the safety of the patients. Rather than also adopt formal avenues in raising their concerns, the nurses have resulted to discussing the principles behind the introduction of the system during their lunch time conversations. Other issues raised by the nurses are based on the inconsistency of the information documented since there is a lack of standardization as pointed out by the NICU and PICU nurses. The location of the computer stations outside the patients has led to the nurses documenting the patient data on pieces of paper then later input the information into the computer later at the end of their shift, something that bothers the nursing staff. As a result, the staffs are continually developing workarounds that they use to resolve the issues that they face with the new clinical documentation system. 

The implementation of the documentation system has largely been faulted since the system implementation personnel move rapidly through the units without much consideration regarding the needs that existed. When conducting the training, there was no consideration about the level of experience of the staff regarding the keyboarding skills and also the documentation ability. The patient population in each of the units was not considered despite its impact on the success of the introduction of the clinical documentation system. Apart from the nurses, all the end users that were supposed to benefit from the system were not satisfied with its implementation including the social worker’s physicians.;

Clinical documentation improvement system

The main alternative, in this case, is moving back to the physical documentation of the patient data using papers. Physical documentation of patient data has traditionally been carried out using forms that were developed and refined over time. As a result, most of the staffs working in the clinical area are familiar with the forms and hence they find it easy to document patient information (Hamilton, 2009). On the other hand, the forms accommodate the processes that exist in the hospitals currently hence making the workflow to continue as expected by the staff. Another reason the staff favors the alternative is the fact that they can carry from one patient room to the next hence making it easy to complete data on a real time basis.;

The use of physical forms is not a viable alternative currently given the constraints that exist when they are used for documentation. One of the main hindrances to using the manual records is the limited accessibility (Hamilton, 2009). The forms can only be accessed by one individual at a time and can only be located at on particular place hence making these records inefficient as a result of the delays they cause especially in decision making. The multiple uses of the patient’s file by different healthcare providers leads to fragmentation of the patient data, and as a result, there is a possibility that most data would end up being lost hence interfering with the quality of care accorded to the patients. The physical files also require that the staff required to deal with patient data are forced to sort out data manually when making reports hence leading to the loss of productivity. 

Documentation for health records

Proposed Solution

One of the specific solutions that can be used to resolve the clinical documentation system issues that have been occurring at the Garrison Children’s Hospital is the implementation of an effective training program. The user training program in healthcare facilities that intend to implement clinical documentation systems tends to suffer from the lack of institutional support about the resources and time allocated to carry out the process (Pantaleoni, Stevens, Mailes, Goad & Longhurst, 2015). However, the existing literature indicates that the provision of end user training for the staff is critical to ensuring that there is adequate satisfaction and actualization before the system is implemented (Hamilton, 2009). Given the specific environments that exist in the different healthcare organizations, no blanket approach can be employed in the training process. As a result, staff involvement is critical to the success of the program as it also contributes towards the development of the unique needs of the different staff that are to be included in the operation of the new clinical documentation system. From a personal experience, it is clear that the healthcare providers are endowed differently regarding skills such as computer use and other related systems. From this experience, it is, therefore, critical to meet all the training needs before implementing any clinical documentation systems to ensure that the healthcare organization can obtain the value for its money from the new method of patient data recording. 

Hospital documentation

Recommendation

Customizing the training is one of the approaches that can be used to ensure that program addresses the needs of the staff and hence ease the implementation. Each unit in healthcare organization presents a different environment and workflow and as a result the training needs for the staff need to be met in a specific manner (Pantaleoni et al., 2015). The training customization can be achieved by getting feedback from the staff as it helps to understand their computer and system use skills. Once the training is carried out, there is a need to conduct a dress rehearsal to ensure that the training has met all the needs that were raised in the initial stages (Hamilton, 2009). Understanding the impact of the new system can only happen in a live environment as this allows the staff to offer comprehensive feedback regarding whether they have understood the new system. In the process, of evaluation of the training, it is critical to identify staff members who are well versed with computer use to act as the in-house experts that can be consulted by the rest of the staff whenever a problem arises. 

The process of addressing the issues related to the clinical documentation system at Garrison Children’s Hospital as outlined in the figure below:

Figure 1: Implementation of Proposed Solution

The nurse managers would be responsible for collecting the feedback from the nurses to understand their needs. The support team and the technology specialists will serve the role of customizing the training of the staff to ensure that their needs are incorporated into the program. The nurse managers would appoint the in-house experts who will, in turn, be responsible for relaying feedback on the progress of the new documentation system. The chief nursing officer will be responsible for coordinating the training sessions and also organizing any refresher training that may be required. 

The timeline for the implementation is about three weeks with the first week being used for obtaining feedback followed by customization of the training and finally the actual training. Allocation of adequate time is critical to ensure that all the staffs are able to gain the required skills. 

One of the main lessons that can be learned from the case is the need to ensure that there is staff involvement in the implementation of any processes in a healthcare organization. Healthcare is largely a service industry and as a result, the human resource is critical aspect of the care provided and as result they need to be adequately involved in change implementation.  

Conclusion

Failure to address the specific needs that exist at Garrison Children’s Hospital affected the outcome of the implementation of the clinical documentation system. The involvement of the staff was minimal, and training that was adopted did not meet their individual needs. Developing a customized training program is critical in the process of ensuring that the system is successful (Hamilton, 2009). As a result, the proposed solution entails taking feedback from the staff to determine their needs and then offer training that best addresses the existing issues. The appointment of in-house experts will help in addressing needs that arise. The involvement of the senior staff in obtaining feedback and scheduling future retraining sessions will also play a critical role in the success of the process.  

References

Hamilton, B. (2009). Electronic health records. Boston: McGraw Hill

Pantaleoni, J. L., Stevens, L. A., Mailes, E. S., Goad, B. A., & Longhurst, C. A. (2015). Successful Physician Training Program for Large Scale EMR Implementation. Applied Clinical Informatics, 6(1), 80–95.