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As a dedicated nurse, Melynda Reeves, BSN, RN, RNC-OB, would love to be able to consider patient care her profession's undisputed top priority. It's just that she knows all too well healthcare is only as effective as the documentation behind it. So, as much as it pains her, Reeves (as well as any other realistic provider, for that matter) has resigned herself to accept that at some point a nurse's responsibilities are going to draw her away from the bedside fairly often.
"It's not that documentation takes precedence over patient care by any means, but there are days where it can consume you," said Reeves, a nurse at Covenant Health System, Lubbock, TX.
It's on these days that nurses can find themselves mired in paperwork, wondering if they're really destined to be healers or pencil pushers. But, according to Reeves, those days at Covenant are fewer and more far between than they've ever been thanks to a new initiative throughout the organization that's led to a reduction in overall documentation protocol and a new sense of worth among the nursing staff.
 Getting 'Lean'
Known throughout the organization as the Lean Process Improvement, the initiative launched in August 2009 as an attempt to reduce the amount of paperwork required for nurses to complete throughout the spectrum of patient care (specifically as it relates to the admissions and discharge processes). Amidst ongoing complaints from nursing staff that documentation was taking too long to complete and repeated results from patient satisfaction surveys that showed patients found their paperwork confusing, administration decided a change was necessary for everyone's sake.
"It became almost as if the patient care was becoming an interruption to our documentation," said Brad Thornton, MSN, CCRN, BA, senior facilitator at Covenant. "The reality was that we had far too much documentation."
Today, Covenant officials say they've reduced their overall documentation by 40 percent, reduced time spent documenting per 12-hour shift by 50 percent and reduced paperwork costs by $30,000.
Process Planning
As a starting point, a documentation forms committee was established, which included Thornton and Reeves, as well as physician and nurse representatives from multiple hospital units, to evaluate all existing pieces of documentation to determine where problems were most prominent and where changes could be made. After a full review it was apparent that major adjustments needed to be made specifically to the admissions and discharge forms and processes.
Time studies were conducted across all units using the existing forms, which were calculated to take 6.1 hours to complete for each 12-hour nursing shift, according to Thornton and Reeves.
"Our dismissal paperwork was redundant and cluttered," Thornton explained. "The print was small, and it was just really designed around old regulatory requirements that are no longer relevant."
The easy work was to enlarge the print and convene with graphic designers within the company to decorate the forms with images and eye-appealing layout. The more difficult challenges were eliminating redundancies and keeping the documentation to a minimum while ensuring all bases were covered.
"We tried to cut down redundancies and 'wasted words,' making sure we still met requirements from the Joint Commission and department of health as the most important elements," Thornton said. "We set up an initial goal to reduce all paperwork by 50 percent."
Covenant also employed the services of a consultation group named Simpler Consulting, which provided staff with a sensei to coach and guide in the decision-making process.
After several meetings and mockups, the committee had become comfortable with attempting to roll out a new process by February. Poster boards highlighting the release of the new process were hung in each unit to serve as reminders and allow nurses to comment on what they believed was working and what wasn't. More than 600 comments were collected, and changes were made in light of them and reissued documentation forms soon surfaced.
Making Change
By the time the new protocol was finalized the committee had determined that overall documentation had been reduced by 40 percent. Specifically targeted, the admissions and discharge sections had been reduced by nearly 75 percent and 25 percent, respectively. Additionally, the committee was able to cut down its paperwork related to critical care from 16 pages to six.
"And we admit about 30,000 patients per year, so that's a sizeable amount of paper," Thornton said.
While the results aren't what Thornton and Reeves would consider flawless, they're certainly satisfied with the progress they've made. Most notably, the new paperwork is said to be better organized in a manner that directs nurses to ask questions that lead to care plan development from admission to dismissal.
"The system forces nurses to think about what they have to do for their patients from admissions to dismissal," Thornton said. "We wanted to make it easy for nurses to be able to complete their paperwork while they were working instead of them having to push it aside to the end of the day. We wanted it to be done in real time as closely as possible."
The main difference, however, has been the noticeably expanded amount of time staff has to spend at the patient bedside, Reeves told ADVANCE.
"Most nurses do not like change, so there was a bit of a rough period where we needed to get used to the new forms and procedures," Reeves explained. "It was a different flow then we were used to in the beginning, and charting has been changed, but we're still able to document everything we need to and I'm hearing very positive feedback."
Mike Chamberlain, president of Simpler's North America branch, told ADVANCE that his company suggests healthcare facilities modify their documentation processes in an effort to improve patient care.
"Organizations should approach this as an enterprise-wide transformation," he said. "Part of that process includes becoming a patient-focused organization where steps that do not add value to the patient are reduced or eliminated. Freeing up time for nurses so they can spend more time with patients is a great example of how Covenant is applying 'lean' thinking effectively across their organization."
Patient Perspective
Approval has also been expressed by patients, particularly regarding discharge packets, which have been reduced and are presented to serve as reminders and prescription guides, not just formalities. For instance, patients are encouraged to post their discharge materials somewhere in their home where they'll see them often.
"It's actually something patients can hang on their refrigerator that can serve as a good reminder for medications they have to take each day instead of a hideous, standardized form," Thornton said. "We've had patients who've come back for readmissions who've made comments about the discharge forms and how useful they are."
Future Change
Next, the documentation forms committee and staff seek to focus on implementing a system for electronic health records (EHRs) to further quicken the documentation process. The newly redesigned protocols are expected to serve as a model for what the EHRs will ultimately look like, Thornton and Reeves said.
"We're building toward an EHR system, but we've tried to lay the groundwork for electronic documentation so when we go to an EHR system it will mimic what we currently have," Reeves added. "You can almost visualize drop-down menus with the forms we have now. The process should convert fairly easily, and we knew if the nursing staff wanted a say in how our EHRs are going to look that this was their first opportunity to do so."
While everyone appears to be comfortable with the process as it now stands, nobody's ready to believe there will never be a need for revisions. Precedent has already been established for that, according to Reeves and Thornton.
"We don't ever want to go back to a situation where our documentation becomes redundant or the forms are not standardized," Reeves continued. "If we ever believe a change to a form is necessary, it will be brought to the forms committee. We won't make changes without getting them approved. Making the process better than even what it is today is always a continual process. We took our goal to reduce documentation very seriously, and I think we did a terrific job."
Joe Darrah is senior associate editor at ADVANCE.
See page 2 for Common Healthcare Wastes
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