Enabling Excellence

Nurses are known for their exceptional dedication and compassion. And successful home health clinicians possess an additional key skill - critical thinking. Unlike their acute-care colleagues, home health and hospice clinicians operate on an island. They can't go ask a neighbor to help start an IV or get the mail carrier's opinion on the best treatment for a particular wound. Most home care clinicians can recall situations where ingenuity was required - such as using a curtain rod as an IV pole. The vast majority enter the profession for all the right reasons - a sincere desire to provide care to the frail and ill.

They would never intentionally provide poor care or fail to comply with a regulation.
But after the laughter has died down from the latest "war story," nurses are left to follow a myriad of complex, confusing and cumbersome regulations and procedures. They also have to contend with policies that can be outdated, poor support systems and a lack of appropriate technology. And then administrators wonder why documentation is incomplete and morale is low among these clearly talented and dedicated clinicians.

Muhlenberg Community Hospital Home Health, located in Greenville, Ky., experienced many of these issues. While they did have an automated point of care system, it required several steps to accomplish even the simplest task. Clinicians, clerical staff and administrators alike were frustrated. But instead of settling for an ineffective technology platform, frustrating processes and low morale, the team at Muhlenberg decided to take action.

A New Direction

While a silver bullet does not exist, there are steps every agency can take to ensure clinical excellence. Agencies certainly should examine all processes and procedures. Administrators at Muhlenberg choose to focus on technology as a key part of a broader strategy.

As the Muhlenberg team reviewed new software systems, leadership included staff members from every area of the organization. "It is so important to include the clinicians who will be directly impacted," said Sharon Burke RN, Muhlenberg's director. "Effective technology will turn your agency upside down as you adopt more efficient and effective processes. You need your nurses to buy into the benefits so they remain committed to the process during the inevitable changes."

The team selected NDoc from Thornberry Ltd as its new software platform. According to Burke, NDoc was selected primarily because it is the most user-friendly system available. "Most nurses will remind you on a regular basis that they did not go into nursing to become computer whizzes," she stated. "Any system must make nurses' lives easier - otherwise you just create another barrier to clinical excellence."

Intelligent Process Controls

Home health and hospice administrators must find the difficult balance between control and flexibility. It's not easy. On the one hand, leadership wanted to ensure that every visit met all regulations and the agency's best practice standards. On the other hand, they also wanted to give clinicians the flexibility to chart they way they felt most comfortable. With NDoc it is possible. NDoc is built with intelligent process controls that enable both agency control and clinician flexibility. Clinicians chart in whatever order they desire. Muhlenberg found clinicians are more likely to use laptops in the home when they can chart as they conduct the visit instead of having to follow a rigid charting methodology. But at the same time, the system ensures all required fields are completed.

Intelligent process controls include three components related to charting. First, field-level edit checks ensure that contradictory information is not entered. While some systems offer this as a batch process for the back office, Muhlenberg's team has found that using a system that offers this to the clinician while they are charting is much more effective and less time-consuming. Additionally, it helps train the clinician to chart more accurately and consistently in the future. The second item is best practice alerts. Best practice alerts are most efficient when they are agency-defined. It reminds the clinicians how leadership expects charting to be completed at the moment they are completing that portion of the chart. Finally, NDoc includes field level help, which is critical. One of the greatest benefits of this functionality is that clinicians no longer have to carry the OASIS Chapter 8 help manual. By providing the information clinicians need, when they need it, Muhlenberg enabled more accurate charting and reduced clinician frustration. Though there were not any significant changes to case mix or outcomes due to back office processes that were in place, the field level help allows the clinician to get it right the first time, decreasing frustration in getting notes back. It also decreased the time spent in the back office, freeing that staff up to help cover visits and work on staff development.

Intelligent process controls also include an employee dashboard. The dashboard provides the day's schedule and, just as importantly, notes items that are coming due, are due or are past due such as recertifications or supervisory visits. The system will not allow the item to be removed from the dashboard until it is completed. Clinicians appreciate the "safety net" of knowing they will be reminded of all upcoming tasks and Muhlenberg's leadership appreciates that important tasks cannot be forgotten.

Enabling Clinical Excellence

Clinical excellence is further enabled by the elimination of clinical pathways. Instead, NDoc uses simpler problem lists. The clinician completes the assessment and charting. The system automatically creates the 485, OASIS and care plan based on the patient's problem list. This is faster, easier for clinicians and ensures the 485, OASIS and care plan are aligned. Burke notes, "By virtue of having used multiple systems throughout my career, I have become a believer in problem lists instead of clinical pathways. No wonder so many clinicians are frustrated when we ask them to follow complex, convoluted systems that can often produce illogical care plans. It is much easier just to have the clinician simply chart during the initial assessment and allow the system to produce a comprehensive, clear care plan that is specific for that patient's individual needs."

Clinicians also appreciate that information entered in one part of the system is automatically known in all parts of the system. Examples are intake information entered by the admission nurse, or an aide's documentation captured on her cell phone, is available to all clinicians assigned to the patient, regardless of discipline. Vital signs captured by home monitors also are available to all assigned clinicians on laptops.

Not only does NDoc disseminate information throughout the system well, it also provides a comprehensive patient summary. According to Burke, "An up-to-date, interdisciplinary patient summary view is more helpful than I can describe. You shouldn't have to go running to 50 places in the system to get a comprehensive view of the patient's condition and whether they are improving, worsening or stable. All of this information is available from a single screen. It enables every clinician to understand what has happened since their last visit, it enables case managers to clearly understand the patient's needs, it facilitates communication with physicians - even enables clear communication if the patient must be admitted."

A single screen patient summary also is beneficial to the on-call nurses who can easily assess and understand the complete situation. This is particularly beneficial in conjunction with NDoc's early alert system. NDoc provides email alerts as soon as a patient begins to decline. This enables the team to intervene quickly, before the situation becomes critical or requires a hospital admission.

Nursing demands the ability to multi-task. The developers at Thornberry understand this demand so NDoc is designed to multi-task with Muhlenberg's nurses. The system allows multiple areas of the patient chart to be open at once. The system even enables simultaneous view-only functionality for a different patient. Muhlenberg's clinicians have found that NDoc does not reduce the amount of time it takes to complete a visit. However, they have found they are better able to focus on the patient instead of worrying about regulatory compliance or wrangling with a difficult computer system. They are able to chart in the home, or at least complete the chart in the car, instead of attempting to chart all of the day's visits at night when they are tired and may not be able to recall every visit accurately. Or worse - charting in the office when another visit could be completed!

The Benefits

The experience of the Muhlenberg team includes many benefits. Overall, clinicians are less frustrated. They have complete information, know what happened on the last visit and have a clear understanding of what must be done during the current visit. They also are no longer frustrated with "the system." An unintended consequence is that employee morale and retention has increased. Happy nurses tend to change jobs less frequently. Muhlenberg's leadership is delighted with NDoc's impact on their retention rates!

Costs have been reduced in many areas of the organization, including the reduction of three clerical FTEs. Nurses make fewer trips to the office, reducing mileage expense and increasing field time. The cost of maintaining complete paper records has been eliminated - dramatically reducing paper, ink, storage and clerical staff expenses.

Not only does NDoc enable clinical excellence, it significantly improves the agency's bottom line. "If you think you can't afford an electronic medical record system, you need to think again," said Burke. "The truth is that agencies cannot afford the cost of not automating. NDoc has paid for itself many times over and I can't imagine trying to run an agency without it."

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