file · Web viewThe principal goal of the Patient Protection and Affordable Care Act (PPACA) is to improve American’s health outcomes and reduce cost of healthcare (Rosenbaum, 2011)

Running Head: QI Revising Electronic Med Administration 1

Quality Improvement Project at Clinton Hospital:

Revising Electronic Medication Administration Process

Telana Fairchild

University of Massachusetts Medical School- Worcester, MA

Graduate School of Nursing

QI Revising Electronic Med Administration 2

The principal goal of the Patient Protection and Affordable Care Act (PPACA) is to

improve American’s health outcomes and reduce cost of healthcare (Rosenbaum, 2011). The

PPACA gives support to the American Recovery and Reinvestment Act (ARRA) (Rosenbaum,

2011). A major component of the ARRA was the financial support of the Health Information

Technology for Economic and Clinical Health (HITECH) act (Brailer & Blumenthal, 2010).

Health information technology (HIT) has been exponentially growing and expanding since the

HITECH act was passed into law in 2009 (Brailer & Blumenthal, 2010). Constructing and

intensifying the electronic health record (EHR) systems has had a significant impact on

improving quality and safety of patient care (Gabriel, Jones, Samy, & King, 2014).

At Clinton hospital, they are enduring the transition of converting to the EHR system. As

a member of the UMass Memorial Health Care (UMMHC) system, Clinton hospital has

adopted the Sorian EHR system (UMass Memorial Health Care [UMMHC], 2014a). UMMHC

began implementation of the EHR at their large tertiary academic medical center, UMass

Memorial Medical Center (UMMMC), in August 2014, before spreading to their local satellite

hospitals (UMMHC, 2014b). Clinton hospital, a 41 bed community hospital, began

implementation in November 2014 (UMMHC, 2014a). Clinton hospital discovered when

developing Sorian EHR, UMMHC used UMMMC’s policies and procedures making

translation to their community hospital a challenge (T. Tronerud, personal communication,

February 25, 2015). Adamantly, the CEO at Clinton was concerned about the ability to

disseminate appropriate policy and procedures for incumbent and new employees along with

the adaptation to the new EHR system (P. Seymour-Route, personal communication, January

21, 2015). In addition, there have been multiple senior personnel changes at Clinton hospital

further complicating the transition to their new EHR (P. Seymour-Route, personal


communication, January 21, 2015). Clinton hospital strives to consistently provide patient

centered care, thus the administration is concerned for the well-being of their patients and staff

during these transitions (UMMHC, 2014a). Therefore, the CEO at Clinton hospital asked the

Graduate School of Nursing (GSN) at University of Massachusetts Medical School (UMMS)

for assistance with disseminating appropriate policy and procedures and revising training for

the EHR system.

The GSN began execution on this request by comparing and contrasting the policies and

procedures for the two hospitals, as well as, analyzing the feasibility of the training for the

EHR system. Rachel Diamondstone, a GSN student, concluded the hospitals had differences

in policies and procedures and the training modules were likely not sufficient and confusing for

the staff at Clinton (personal communication, Janurary 28, 2015). Now informed, the GSN

Doctoral Nursing Practice (DNP) student began focusing on the specific issues related to

electronic medication administration (MAK) within their EHR at Clinton.

As part of the integrative practice experience, the DNP student will lead a quality

improvement project for MAK education and standardization of the verification process to

improve the safety of patients at Clinton Hospital. The competency essentials for the DNP

student distinguish requisite skills and knowledge useful to assist in quality improvement

projects. Understanding of organizational and systems leadership for quality improvement and

systems thinking allows the DNP student to translate research into practice, subsequently

improving nursing process and patient outcomes (American Association of Colleges of

Nursing [AACN], 2006). Information system and patient care technology is included for the

DNP’s education, contributing to the DNP student’s knowledge and ability to help Clinton with

their EHR system to improve the outcomes of patients (AACN, 2006). In addition, the DNP


student has effective leadership skills that will facilitate collaboration among an

interprofessional team and oppress any impediments to an interprofessional culture (AACN,

2006). At Clinton, an interprofessional team including nursing, pharmacy, and administration

was created to inform and assist the GSN student and facility with this quality improvement

project. The DNP student became the leader of the project after establishing the core issues

and priorities for Clinton hospital. Once the interprofessional team had corroborated specific

aim and goals for this quality improvement project, the DNP student began a literature review.

A literature search in PubMed, Ovid, and GoogleScholar with search terms including

electronic health record, electronic medical record, implementation science, and hospital

implementation of electronic medication administration yielded over one hundred thousand

articles. Articles were narrowed down with limits specific to this improvement project, within

the last five years, and in English language. Articles were further reduced after eliminating

duplications and those not relevant to search based on abstract or title of the article. The

remaining twenty-six articles were appraised for strength of the study and information

pertaining to implementation of EHR in a hospital. Twelve articles were kept for their

relevance and strength of evidence; these articles were used to evaluate the evidence based

practice for implementing EHR in an acute care setting.

According to Fritz and colleagues, implementation of an EHR takes a holistic approach

and to be successful there are core components organizations must consider before beginning

the process (2015). These principal elements are the functionality of the EHR system, the

organizations structure and support for implementation, and the technical infrastructure for

new technology (Fritz, Tilahun, & Dugas, 2015). When an organization has collaboration with


large corporations, they are more likely to overcome challenges due to more resources and

support staff (Gabriel, Jones, Samy, & King, 2014). Also, organizations should ensure policies

and procedures are in place prior to implementation (Maust, 2012).

Correspondingly to these organizational structures the human factor is essential to the

success of implementing a new EHR system (Colligan, Potts, Finn, & Sinkin, 2015). There is

a significant cognitive impact on the staff during the first two weeks of implementation of a

new EHR system. Increase in cognitive workload on staff could negatively impact the

outcome and safety of patients. Development of a technique to evaluate who needs additional

support and consider methods to reduce cognitive workload during implementation of EHR

would overcome negative impacts (Colligan, Potts, Finn, & Sinkin, 2015).

Additional, factors like attitudes about implementation of EHR can negatively impact

adaptation and become a barrier to successfully executing new technology (Turner, 2010). A

case study of EHR implementation in a mental health hospital discusses the culture and

attitudes of the staff pre and post implementation are valuable. These researchers suggests it is

important to involve the core users in the decisions about the EHR rather than forcing a system

upon them (Takian, Sheikh, & Barber, 2012). One of the top four national barriers to EHR

implantation is the discernment it will decrease workflow. Similarly in Massachusetts, one of

the top three barriers was the concern for loss of productivity. However, Turner suggests the

solution to overcoming this barrier is focusing on computer literacy. First, by having a method

to assess individual literacy and then, stratify teaching methods based on targeted literacy gaps

(Turner, 2010).


Many articles discuss methods and modules to improve the training and education of staff

for implementation of new EHR systems. One case report from the Midwest at a critical

access hospital explained having a method of evaluating employees’ knowledge after training

but before “go-live” would be valuable (Maust, 2012). An additional suggestion from Maust is

to develop competencies and criteria to use for new orientation and to keep incumbent staff

using the system adequately (2012). Another case report about implementation of EHR in a

large ambulatory setting on the East coast proved to have valuable information on training

based on feedback they received from their staff (Bornstein, 2012). Majority of staff agreed

training is more beneficial in the live environment; therefore, having “super-users” available is

better than classroom training. A case study of EHR implementation in a mental health

hospital agrees live environment teaching is the users preferred method of training (Takian,

Sheikh, & Barber, 2012). More valuable lessons about training for EHR implementation are

using web-based pre-training modules prior to classroom sessions and training workflows as

opposed to training functionality of the system (Bornstein, 2012).

A training model for new staff orientation was developed by a team at a regional hospital

in the mid-west (Stromberg, 2011). They used feedback from previously trained staff to

modify and develop an improved training module for their EHR system. Key concepts to their

model included: continually evaluate training and usability of EHR, match information to

specific roles, use real-life scenarios, provide break-out sessions between training, and allow

elective review training sessions as needed (Stromberg, 2011).

It is important to have successful implementation of an EHR to avoid staff workarounds

or refusal to use program (Schoville, & Titler, 2015). These pitfalls could lead to patient safety


concerns. So, theoretical frameworks from implantation science and technology adaptation

models were used to create a new Integrated Technology Implementation Model (ITIM). ITIM

focuses on organizational and individual adaptation with emphases on the end users feasibility

of the system. The goal ITIM is to better understand adaptation of technology in healthcare so

patient’s safety and end user satisfaction is achieved (Schoville, & Titler, 2015).

Articles alluded to quality and safety concerns that are likely to occur during the

implementation of a new EHR. The Yorkshire Contributory Factors Framework, developed by

Lawton and colleagues, enables a systematic approach of reviewing safety and quality

concerns for patients in hospitals (2012). Outlined in the framework are organizational factors,

policies and procedures, training and education, and central support of structure are all

concerns at Clinton hospital during the implementation of the EHR (Lawton, et al., 2012). As

discussed, the EHR was developed using a different organization’s policies and procedures.

Now, Clinton is struggling with revising, approving and distributing the new policies and

procedures for their EHR. Many of these policies and procedures have been revised but

neither approved nor distributed due to the changes in senior management (T. Tronerud,

personal communication, March 11, 2015). Training and education is another interest for

safety and quality, as Clinton doesn’t have personnel responsible for educating staff (Lawton,

et al., 2012). The responsibility is then given to a staff nurse and pharmacist who were left

ensuring the continuing education and training was completed for the EHR and new policies

and procedures (K. Cousins & T. Tronerud, personal communication, March 11, 2015). The

lack of having an educator and the needed staff for implementation of information technology

is one more organizational factor that could lead to patient safety and quality complications

(Lawton, et al., 2012). Just as the ITIM suggest need for the technology support is essential to


successful implementation; however, Clinton doesn’t have a resource accountable for ensuring

the support for new information technology (Schoville, & Titler, 2015 & T.Tronerud, personal

communication, March 11, 2015).

According to the Yorkshire Contributory Factors Framework, the local working

conditions are more likely to cause patient safety and quality issues, than the organizational

factors (Lawton, et al., 2012). Senior management changes at Clinton have created struggles

with supervision, leadership, and management of staff. At Clinton, there is a new “acting”

CNO from outside the organization, many units without a dedicated manager, and lack of

nursing and information technology leaders (P. Seymour-Route, personal communication,

January 21, 2015). In addition, Clinton currently has contracted hospitalist and pharmacist

which are difficult to hold to hospital standards, training, and management (T.Tronerud,

personal communication, March 11, 2015). The ITIM agrees leadership and key roles are

necessary to successful adopt new technology (Schoville, & Titler, 2015).

Furthermore, these contracted employees affect the team work which is one of the

situational factors of the Yorkshire Contributory Factors Framework. The situational factors

are in closest proximity to active failures according to the framework and are the most likely to

lead to patient safety and quality errors (Lawton, et al., 2012). In addition, there are individual

factors of difficult behavior and attitudes of the staff at Clinton. The end users are equally

important in the ITIM for successful implementation of a new EHR (Schoville, & Titler,

2015). Perhaps, the previous discussed organizational issues could be liable for some of these

observed attitudes and behaviors. Obviously, there are many reasons for improvement of the

EHR process and accompanying factors at Clinton hospital.


The Kirkpatrick Model will be used to guide and determine the success of the

improvement project, the training modules, and the revised process for standardizing

verifications. The Kirkpatrick Model was developed in 1950’s to analyze and evaluate

training based on four categories: reaction, learning, behavior, and results. However, the

Kirkpatrick Foundation modified this model and added an additional level, return on

investment and now the model is widely used beyond training evaluation (Kirkpatrick Partners,

LLC., 2009). Each of these categories evaluates the project, training, and process at different

levels including the learners’ perception, knowledge, ability to apply learned skills, overall

success of the project, and return on investment (Kirkpatrick Partners, LLC., 2015). For every

category there will be measureable metrics for the project, modules and process.

Shortly after implementation, Teresa Tronerud, a pharmacist, began collecting data in log

form using Microsoft Word. Each day since implementation in November she has manually

entered verification issues (T.Tronerud, personal communication, March 16, 2015). In order to

make this data manageable and measureable, categories were defined and totals were given for

each category. Now these logs could be transformed into a Pareto chart so priority can be given

to top issues (Provost, Lloyd P; Murray, Sandra (2011). These logs were also counted for

number of interventions each day and average totals were noted. Goals for this project were to

reduce the number of issues per day and standardized the verification process to avoid creating

these known issues.

Training and workflows were developed to aid in improving and standardizing the

verification process. Surveys will be given to the staff pre and post intervention to determine

their perception about the project and training. For each instructional objective, a test patient


case will be utilized to demonstrate the knowledge and skills of the staff after receiving the

training and education on workflows. After each instructional training, the modules and

workflows will be updated based on feedback to improve the success of the education. To

ensure future success there will be annual competencies and training required using these

modules.

Overall reduction in the volume of interventions created per day and staff competency

and satisfaction will determine the success of the quality improvement project. If reduction in

intervention volume is accomplished and staff satisfaction is achieved, then return on investment

will be established. Since the end result is to improve patient safety, the interprofessional team

will need to address this concern with administration and determine their method of measuring

patient safety data. As patient safety data may be sensitive to the organization.

In conclusion, Clinton hospital aspires to create a patient safe environment through use of

education, research, and improvements (UMMHC, 2014a). The CEO and administration

promptly addressed valid concerns related to new EHR system and patient satisfaction and

safety. After meeting with an interdisciplinary team and reviewing data, priorities and goals of

the improvement project were determined. Best evidence based practice determines essential

process to transition acute care settings to use of EHR system for success. These core concepts

include use of training in a “live environment”, focused on end users and workflows, as well as,

making sure policies and procedures and support for the new structure are in place. The DNP

student has developed interventions based on this best evidence based practice and formatted

new training modules to Clinton’s needs. There will be ongoing assessment and evaluations

using measurable data to revise and determine the success of each portion of the project. The


long-term goal is to have a process in place for these changes to be sustainable. Sustainability

will be created by including the staff in the process and annual based competencies for the staff.

Even if their EHR system changes in the next five years, involving the staff in the process will

leave them with the knowledge and skills to create successful transitions. Also, since they are

associated with a large corporation, UMMMC, then using their resources to help support Clinton

is another vital component to ensuring success. The partnership with the GSN at UMMS will

also offer Clinton future support in years to come to continue to improve the quality and safety

of their care.


References:

American Association of Colleges of Nursing (AACN). (2006). The essentials of doctoral

education for advanced nursing practice. Retrieved from

http://www.aacn.nche.edu/publications/position/dnpessentials.pdf

Bornstein, S. (2012). An integrated EHR at northern california kaiser permanente: Pitfalls,

challenges, and benefits experienced in transitioning. Applied Clinical Informatics, 3(3),

318-325. doi:10.4338/ACI-2012-03-RA-0006

Brailer, D.J. & Blumenthal, D. (2010). Guiding the health information technology agenda.

interviewed by david J. brailer. Health Affairs (Project Hope), 29(4), 586-595.

doi:10.1377/hlthaff.2010.0274

Colligan, L., Potts, H. W., Finn, C. T., & Sinkin, R. A. (2015). Cognitive workload changes for

nurses transitioning from a legacy system with paper documentation to a commercial

electronic health record. International Journal of Medical Informatics, doi:S1386-

5056(15)00063-5

Fritz, F., Tilahun, B., & Dugas, M. (2015). Success criteria for electronic medical record

implementations in low-resource settings: A systematic review. Journal of the American

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http://www.aacn.nche.edu/publications/position/dnpessentials.pdf


Kirkpatrick Partners, LLC. (2009). The Kirkpatrick Model. Retrieved from

http://www.kirkpatrickpartners.com/OurPhilosophy/TheKirkpatrickModel

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(Ed.). Retrieved from http://www.isixsigma.com/dictionary/kirkpatrick-four-levels-

evaluation-model/

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incidents in hospital settings: A systematic review. BMJ Quality & Safety, 21(5), 369-

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Documents

file · Web viewThe principal goal of the Patient Protection and Affordable Care Act (PPACA) is to improve American’s health outcomes and reduce cost of healthcare (Rosenbaum, 2011)