Project Giving U Back T.I.M.E.
(Together Implementing Meaningful and Essential Documentation)
Background
Project T.I.M.E.
Reducing Nursing Documentation Burden Project Aims to Give U Back T.I.M.E.
Electronic health records (EHRs) are linked to documentation burden that results in clinician burnout. The American Medical Informatics Association (AMIA) is leading the 25x5 Symposium call-to-action national goal to reduce clinician documentation burden on U.S. clinicians to 25% by 2025.
In the 2021 Nursing Staff Wellbeing Survey completed by 1,212 nurses at a large, public academic health system, reducing the burden of documentation was among the top 3 recommendations to create a healthier work environment.
Six Domains of Documentation Burden
The American Nursing Informatics Association (ANIA) built a framework showcasing six major domains contributing to the overall burden of EHR documentation. Each field has several areas of overlap and applies to most healthcare settings. It's essential to recognize that no single entity can independently resolve this issue. Multiple stakeholders must work in partnership to achieve a future state of EHR documentation that is patient-centric and user-friendly.
Source: ANIA Six Domains of Burden
Usability
"EHRs don't follow evidence-based usability and human factors design principles. Instead, the design was based on historical paper records, which led to extra time spent scrolling, clicking, and searching for information."
Reimbursement
"Payors (such as CMS, Blue Cross, and Anthem) require specific documentation, administrative charting, and coding for reimbursement."
Regulatory
"There are documentation requirements reinforced by accreditation agencies (such as Joint Commission, Stroke Program Certifications, and State Regulatory Agencies)."
Interoperability
"Poor configuration of the internal and external structures results in duplication and re-entry of data that already exists in the electronic system."
Quality
"Regulatory agencies such as NDNQI (National Database of Nursing Quality Indicators), healthcare organizations, and the government require documentation demonstrating quality patient care was met."
Self-Imposed
"Organizational culture's influence on what should be documented can exceed what is essential for patient care, including:
- Fear of litigation
- "We've always done it this way"
- Misinterpretation of regulatory standards
- Special interest groups add documentation by clinicians to meet their needs"
Project Scope
Our core team consisted of four nursing informatics (NI) fellows and mentors from the NI team at a large, public academic health system. Each fellow pursued a different area of documentation, and my focus was on the Daily Cares and Safety (DCS) flowsheet.
This flowsheet promotes regular rounding by nurses and care partners to meet patient needs, including safety, mobility, hygiene, and nutrition. In each standard 12-hour shift, it's the shared responsibility of nurses and care partners to document each hour (using 24-hour military time) within DCS.
Day shift nurses document every two hours: 0800, 1000, 1200, 1400, 1600, and 1800. Similarly, night shift nurses chart under these times: 2000, 2200, 0000, 0200, 0400, and 0600. Meanwhile, care partners document under all the odd hours.
The 22 units in scope include all inpatient, adult medical-surgical, and intensive care floors at UCLA Health. A significant variance in the documentation excluded specialty areas such as pediatrics, OB, PACU, and ED.
This flowsheet promotes regular rounding by nurses and care partners to meet patient needs, including safety, mobility, hygiene, and nutrition. In each standard 12-hour shift, it's the shared responsibility of nurses and care partners to document each hour (using 24-hour military time) within DCS.
Day shift nurses document every two hours: 0800, 1000, 1200, 1400, 1600, and 1800. Similarly, night shift nurses chart under these times: 2000, 2200, 0000, 0200, 0400, and 0600. Meanwhile, care partners document under all the odd hours.
The 22 units in scope include all inpatient, adult medical-surgical, and intensive care floors at UCLA Health. A significant variance in the documentation excluded specialty areas such as pediatrics, OB, PACU, and ED.
Adult Medical Surgical (Med/Surg) Daily Cares Flowsheet
Adult Intensive Care Unit (ICU) Daily Cares Flowsheet
Excluding:
- Emergency Department (ED)
- Post-Anesthesia Care Unit (PACU)
- Obstetrics (OB)
- Pediatrics
Inclusion Criteria
An inclusion criterion was formulated to standardize the approach to examining nursing documentation for its purpose and usefulness. The criteria included:
A)
Required to provide care to the patient and accessed by other care team members and/or by the patient.
D)
Non-duplicative, relevant and value added.
B)
Mandated by policy, regulatory, compliance, reimbursement or external reporting mandates.
E)
Triggers an action to another care team member.
C)
Necessary to document that patient refused ordered care.
F)
Information that does not meet any of the inclusion criteria will go through governance review for deletion.
Project Goals
#1
Develop Guiding Principles and Inclusion Criteria for nursing documentation.
#5
Increase the amount of time nurses have to spend with the patients.
#2
Increase nurse efficiency and effectiveness.
#6
Standardize documentation across nursing units.
#3
Decrease redundant and minimally used flowsheet rows and choices list options.
#7
Increase usability by decreasing clicks, scrolling, screen flips and free text comments.
#4
Enhance patient experience and improve clinician well-being.
