At the University of Louisville Hospital (ULH), the patient care model is based upon a framework of patient and family-centered care. Patient and family-centered care (PFCC) is an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families (Johnson & Abraham, 2012). It redefines the relationships in health care and leads to improved health outcomes (Johnson & Abraham, 2012).
Patient and family-centered practitioners recognize the vital role that families play in ensuring the health and well-being of infants, children, adolescents, and family members (Clay & Parsh, 2016). They acknowledge that emotional, social, and developmental support are integral components of health care. They promote the health and well-being of individuals and families and restore dignity and control. PFCC is an approach to health care that shapes policies, programs, facility design, and staff day-to-day interactions. It leads to better health outcomes, wiser allocation of resources, and greater patient and family satisfaction (Clay & Parsh, 2016). Core Components of PFCC include: respect and dignity, information sharing, participation and collaboration (Johnson & Abraham, 2012).
A core component of PFCC model at ULH is the Family Presence Policy. The policy defines “Partners in Care” to be “individuals that the patient deems as integral in the process of caring and recovery from illness”. Ideally, patients are asked for this information at the beginning of their hospital stay. The names and designations of those individuals is then documented in the patient record by nurses. Documentation of such individuals affords those identified as “Partners in Care” 24-hour visitation, facilitating their ability to be present and partner in the care of the patient. Unfortunately, compliance with documentation of this information was hindered by the limitations of existing documentation processes.
In 2016, the organization implemented a new electronic health record system (Cerner). Nurses have reported that Cerner is helpful as a care coordination partner (Moore & Fisher, 2012). Technology, such as Cerner, improves compliance with documentation requirements, improves communication, and results in a more accurate method of data collection (Keasberry, Scott, Sullivan, Staib & Ashby, 2017).
Cerner, like other electronic documentation systems, has been programmed to include a list of required tasks for each nurse/healthcare provider. Missing information is flagged until required documentation has been completed. These types of reminders have been shown to improve documentation by healthcare providers (Keasberry et al., 2017) and are perceived as helpful by clinical nurses (Sidebottom, Collins, Winden, Knutson & Britt, 2012).
Purpose
The purpose of this project is to describe how clinical nurse involvement with the design and implementation of a new electronic health record system improves nursing documentation and enhances the institution’s patient care model as demonstrated by improved documentation of “Partner in Care”.
Methods
Nursing documentation of use of the Family Presence Policy (Partner in Care) is considered a part of the required nursing documentation for each patient upon admission to inpatient areas. Prior to implementation of the new electronic documentation system, Cerner, nursing documentation of use of Family Presence Policy (Partner in Care) was done manually by clinical nurses at ULH. There were no reminders sent to each nurse to document this core component of PFCC.
Clinical nurses employed by ULH have been heavily engaged in the design and implementation of technology related to implementation of Cerner. For example, clinical nurses from a variety of clinical specialties were removed from patient care and asked to be Subject Matter Experts (SME). As SME, clinical nurses were responsible for collaborating and developing a successful documentation platform within Cerner that met the specific needs and workflow of their respective clinical areas. Responsibilities included but were not limited to, the selection of information deemed essential for documentation, identification of required documentation, advice on current workflow, and communication of the needs of clinical nurses to the development team.
As a result of input from clinical nurses, a function was built into Cerner to allow documentation of patient preferences for “Partners in Care”. In addition, this item was added to the task list function to facilitate documentation of this information. Documentation of PFCC preferences was not a process pre-built into the Cerner program as it is unique to the ULH nursing workflow. A reporting function was developed to extract key areas of documentation such as “Partner in Care” following go-live with the new system.
Outcomes
At ULH, the patient care model is based upon a framework of PFCC. It is important that all policies related to PFCC are consistently implemented, e.g., Family Presence Policy. One way to measure the effective implementation of the policy is to audit the documentation of “Partners in Care” in the patient medical record.
Baseline data before implementation of Cerner indicated a documentation rate for “Partners in Care” of 51.4% of inpatient admissions. Post-intervention data demonstrated that implementation of Cerner has improved rates of documentation of “Partner in Care” to 63% and 65% at one and two months post go-live respectively.
Implications
Implementation of a new electronic health record documentation system with leadership by clinical nurses led to improvements in documentation of “Partners in Care” thereby improving communication of patient visitor preferences amongst healthcare providers. Additionally, the updated system led to a more efficient way to track nursing documentation of use of Family Presence Policy (Partner in Care). Involvement of clinical nurses was key to the success of this project. Clinical nurses in the role of SME continue to focus on improving staff understanding of documentation requirements related to organizational quality metrics. Monitoring of quality metrics such as “Partner in Care” remains ongoing.
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