Paper
Sunday, November 4, 2007

123
This presentation is part of : Transdisciplinary Healthcare Initiatives
Organizational Transformation: Linking Documentation to Patient-Centred Care
Agnese Bianchi, RN, BScN, MN1, Heather Pollex, BA, BScN, MSc (T), EdD2, Sandra Grgas, RRT, BA3, and Jane Moser, RN, BScN, MN2. (1) Nursing Informatics, University Health Network, Toronto, ON, Canada, (2) Corporate Nursing, University Health Network, Toronto, ON, Canada, (3) Allied Health, University Health Network, Toronto, ON, Canada
Learning Objective #1: describe how one organization redesigned its clinical documentation system using John Kotter’s (1996) eight-stage process of creating major change.
Learning Objective #2: discuss how patient-centred care can be effectively captured using Susan Lampe’s (1997) focus charting methodology with a structured progress note based on the acronym, PCARE.

Too often, narrative clinical documentation captures the care that nurses provide to patients but fails to capture the patient’s point of view, or the rationale for the care provided.  In preparation for the electronic patient record, a Canadian multi-site quaternary academic health centre reviewed and modified its paper-based documentation system. Its goal was to reflect the organization’s patient-centred care philosophy in its documentation and to better communicate clinician assessments, actions and patient outcomes.

This presentation will illustrate how documentation was linked to reflect practice as well as the organization’s values and patient care philosophy using interdisciplinary collaborative working groups. Guided by Susan Lampe’s (1997) focus charting methodology, nursing and allied health professionals developed a new and innovative acronym, PCARE, to structure the narrative notes. 
Grounded in a collaborative partnership between nursing and allied health professionals, the change process began. This presentation will describe how John Kotter’s (1996) eight-stage process of creating major change was used to steer this interdisciplinary documentation initiative. Evaluation of the transformation will also be discussed along with efforts to sustain the major change.