EMR Case Study: Clinical Documentation Optimization
WCBF’s 10th Annual Lean Six Sigma and
Process Improvement in Healthcare Summit
May 11, 2011
Julie BaranCertified Six Sigma Master Black Belt
Memorial Hermann Healthcare System
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Julie Baran - Bio
Julie Baran is a Certified Six Sigma Master Black Belt with 20 years of nursing
experience. Julie is originally from Ohio, where she received her Bachelor’s Degree in
Nursing from Bowling Green State University. She worked as a critical care and
invasive cardiology nurse at the Cleveland Clinic for ten years.
In 2001, Julie moved to Houston to work for the Memorial Hermann Healthcare System
and was part of the team that rebuilt the Invasive Cardiology department after it was
destroyed during Tropical Storm Allison. Since then, Julie has worked in nursing
leadership at the Memorial Hermann Texas Medical Center and Southwest hospitals.
Julie achieved her Six Sigma Green Belt in 2005, Black Belt certification in 2008, and
Master Black Belt certification in April, 2011. Julie utilizes her nursing and Six Sigma
experience to work on large, multiple-hospital initiatives. Most recently, she applied her
DFSS skills to develop a new program at Memorial Hermann to train graduate nurses
following graduation and licensure.
Julie lives in Missouri City, Texas with her husband David, and daughters Alison (13)
and Jenna (7). Besides spending time with family, her favorite hobbies include reading,
technological toys, and swimming.
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Who We Are
Serving greater Houston area, 4 million residents
- One quarter of inpatient market share
10 acute care hospitals
- Tertiary academic medical center (800+ beds) with a
children’s hospital, air ambulance, transplant services
- Eight community hospitals located throughout greater Houston
area
- Dedicated heart & vascular infrastructure
Array of rehabilitative, ASC and outpatient services
- 2 inpatient rehab hospitals and multiple sports
medicine/outpatient rehab centers
- 7 ambulatory surgery centers, 16 outpatient imaging centers
2009
System
2010
4 Hospitals
2010
2 Hospitals
2010
2 Hospitals
2005 - 2010
System
Beds (licensed): 3,286
Annual emergency visits: 323,258
Annual deliveries: 21,536
Annual Life Flight air ambulance missions: 3,185
Annual community benefit: $ 330M
Employees: 19,012
Medical staff members: 4,194
Physicians in training: 1,324 (physicians and fellows)
Residency programs: 26
Fellowship programs: 48
4
Quick Stats and Facts
5
EMR History at MHHS
*As of Feb, 2011 only 3.2% of U.S. hospitals have achieved Stage 6 and 1.0% have achieved Stage 7 (complete EMR) - Data from Healthcare Information Management Systems Society AnalyticsTM Database © 2011
EMR introduced at Hermann hospital (beta partner with Cerner)
Technology and business transformation initiative launched to bring all facilities onto one
common platform (Cerner integrated system applications)
Initiative resumes
1996
1997 -
2000
2000
2002 -
2008
Other facility acquisitions, Complex IT structure - patchwork of disparate systems
EMR HIMSS Stage 6* (full deployment of CPOE - Computerized Physician Order Entry) achieved in
3 out of 10 Memorial Hermann facilities2010
Hermann merged with Memorial1997
Standardized system documentation policy replaces facility-based paper policies2009
Tropical Storm Allison caused extensive flood damage to several facilities; funding diverted away
from initiative2001
Clinical Documentation Environment in 2009
Nursing survey results reflecting increasing
dissatisfaction with documentation
Lack of communication and clarity resulting in
growing antagonism between nursing and IT
Leadership concerns with feedback from staff
High priority request from nursing leadership
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Project Charter
Problem StatementAs documentation requirements and
electronic solutions increase, the workflow of
clinical documentation needs to be evaluated.
Steps have been taken to standardize nursing
documentation and meet national guidelines
and standards of care. We have an
opportunity to improve efficiency, quality, and
satisfaction of the documentation process.
Project Scope• Evaluate work flow in Med/Surg, ICU, and
NICU units (NW, SL, SW, & TMC)
• Exclude areas without AC4 (ED, Peri-Op,
Northeast) and specialty areas (TIRR,
Rehab).
Assessment Objectives – by July 10,
2009
1. Voice of the customer assessment
2. Identification of issues (people, process,
technology)
3. Findings & improvement
recommendations
Resources
Executive SponsorsDavid Bradshaw, CIO
Tim Bevelacqua, System Exec/Critical Care
Helen Powers, System Exec/Six Sigma
Business ChampionsSusan Jadlowski, CNO/COO NW
Steven Weber, CNO SL
Brenda Lyon, CNO TMC
Victoria King, CNO SW
Project Core Team
John Cramer, MBB Mentor Kathy Sater, ISD Lead
Brian Banner, BB Julie Baran, BB Lead
Michelle Chang, BB Shanna Harris, MBB
Jessica Kitchens, GB Jackie Wickstrand, MBB
Facility Clinical Experts
Northwest Sugar Land Texas Medical CenterShelita Anderson, Med/Surg, Denise Austin, GB Karen Brumley, Pedi
Peds, Oncology Angela Green, ICU, Delores Corman, Pedi
Aaron Arias, Med/Surg Med/Surg Andy Draper, ISD
Althea Bennett, GB Gail Rose, ISD Brian Graham, Med/Surg
Margaret Geater, ICU Dawn Johantges, ICU
Patricia Leal-Mack, ISD Southwest Kathy Masters, MBB
Melanie Lewis Michelle Rhea, NICU Kathy Sater, ISD
Beverly Edwards, NICU Nancy Schryer
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Voice of the Customer
We began by reaching out and hearing what you had to say and quickly
learned how eager you were to share your comments with us!
Online SurveysInterview &
Focus Groups
Face-to-Face
Interviews
31 Directors, Managers,
and Executives
1,155 Responses
8 Facilities
135 Staff Nurses
at TMC, NW, and SGL
Over 3,000 comments collected and analyzed
Voice of the CustomerFront-Line Staff
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Face-to-Face Interviews
3 facilities (TMC, SL, NW)
33 Med/Surg, ICU, and NICU units
153 clinicians were interviewed;
138 were RNs
Interviews were done during all
shifts
485 comments & suggestions
Voice of CustomerScope and Approach
Online Survey
Open to all MHHS acute-care
facilities, except NE
Available for 13 days, including 2
weekends
1155 total responses (RNs &
other clinicians)
2549 comments & suggestions
Online Survey & Face-to-Face Interviews, April – May 2009
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Motion Time StudyApproach
4 Facilities
10 Nursing Units
41 Nurses Observed
3 Observers
108 Observation Hours
Observation Details: 4 hour shifts Shifts ranged from 5AM – 9PM Covered change of shift from
night-day and day-night
Motion Time Study, May 2009
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From Comments to Recommendations
We sorted the comments into distinct
opportunities across unit types and three
categories: People, Process, and
Technology…
…and developed proposed improvement recommendations.
3,000 Comments 1,454 Distinct Opportunities 60 Recommendations
Make It
Better! M/S ICU NICU
PEOPLE
PROCESS
TECH
535 462 457 1454
174
520
256 256 248 760
48 55 71
231 151 138
M/S ICU NICUMax
Count
PEOPLE
PROCESS
TECH
Unit Type Total 58 57 59 60
99
19 19 19
30 29 30
10
19
31
10
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Evaluating theRecommendations
Each recommendation was assigned two scores based on value
and implementation complexity.
The project team assigned the
Complexity score
You assigned the
Value score
PROPOSED RECOMMENDATIONS
#1 __________
#2 __________
#3 __________
#4 __________
#5 __________
…
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Prioritizing the Recommendations
Recommendations were plotted on a chart based on their
value and complexity scores and a proposed timeline was
developed.
Prioritization
Matrix
Proposed
Timeline
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Summary Findings
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Voice of the CustomerHeadlines
“Why so often?”FREQUENCY OF DOCUMENTATION
“Why so much?”AMOUNT OF DOCUMENTATION
“Why so many clicks and screens?”EFFICIENCY OF CHARTING IN THE SYSTEM
“Why so many changes and updates?”TRAINING AND EDUCATION
Success MetricSystem Changes & Updates
Pre Aug ‘09: Within 12 month period, 32 production changes to AC4
documentation system, with as many as 5 updates within a span of 8 days.
Post Aug ‘09: Quarterly updates Exceptions made for emergent, regulatory, safety, and seamless (i.e., cosmetic
non-functional) updates.
Source: News You Can Use Updates; InSite17
August 2009
We observed nurses and assigned their performed tasks
into 6 categories:
Documentation
Care Coordination
Unit Related Functions
Nonclinical Activities
Direct Patient Care
Non-Value Added
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Documentation TimeBy Task Category
The average documentation task takes 1.6
minutes to complete
Half of documentation tasks take less than
1 minute
Longer tasks such as admission or
discharges may take up to 22 minutes
The average direct patient care task takes
2.6 minutes to complete.
Half of direct patient care tasks range from
1.6 minutes to 20 minutes.
Source: Motion Time Study, May 2009
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Time Lag in Charting Tasks
2.4The average hour difference between the time a task is scheduled and the time it
is actually charted.
0
1.2 3.5 53
Time
Lag
(hrs)
Minimum amount
of time difference
25% of the time, the time
lag can take anywhere
from 3.5 to 53 hours
50% of the time, the time
lag is less than 1.2 hours
Source: AC4 System Data, April - May 2009
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Documentation TrendsBy Hour in Shift
1413121110987654321
50
40
30
20
10
0
117
Sa
mp
le M
ea
n
__X=20.51
UCL=30.64
LCL=10.38
1
1
1
1
NW Hospital 3/6/09 AC4 Entries by Normalized Shift Hour
134 110 112 103 110 106 102 73 82 60 65 29 4 '----->
AC4 Entries
Coding
Nurses
The quantity of documentation entries was also analyzed to highlight
trends throughout one shift.
Documentation activity is the
highest during the first 2 hours
of a shift.
Source: AC4 System Data, April / May 2009
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Recommendations Summit
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Recommendation “Buckets”
Recommendations were grouped into six buckets
1. Policy (15)
2. Education (11)
3. Leadership (3)
4. Change Management (7)
5. Available Technology (15)
6. Future Technology (9)
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Phase 1 – Aug ’09 (22 recommendations)- Available Technology (7)
- Change Management (2)
- Education (6)
- Policy (7)
Phase 2 – Nov ’09 (23 recommendations)- Available Technology (7)
- Change Management (5)
- Education (5)
- Leadership Decisions (3)
- Policy (3)
Phase 3 – Feb ’10 (1 recommendation)- Policy (1)
Phase 4 – Future TBD (9 recommendations)- Available Technology (1)
- Future Technology (8)
Undetermined (5 recommendations)- Future Technology (1)
- Policy (4)`
Implementation Timeline
ID Task Name
1 PHASE 1 - AUG 09
2
3 PHASE 2 - NOV 09
4
5 PHASE 3 - FEB 10
6
7 PHASE 4 - FUTURE TBD
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9 UNDETERMINED
12 19 26 2 9 16 23 30 6 13 20 27 4 11 18 25 1 8 15 22 29 6 13 20 27 3 10 17 24 31 7 14 21 28 7 14 21 28 4 11 18 25 2 9 16 23 30 6 13 20 27 4 11
Jul '09 Aug '09 Sep '09 Oct '09 Nov '09 Dec '09 Jan '10 Feb '10 Mar '10 Apr '10 May '10 Jun '10 Jul '10
75% of all recommendations
delivered in first 3 phases (August
2009 through February 2010)
Further analysis revealed these
recommendations were not
feasible at this time
Phase 4 put on hold due to
other system priorities
Phase 1 ImprovementsFocus on Addressing Critical Needs
Before After
Q 2 hour Frequent Nursing
InterventionsFrequent Nursing Interventions task
removed; chart by exception
Q 2 hour Peripheral IV
documentation required
Peripheral IV task removed; now included
in assessment. Other documentation as
needed (chart by exception).
Q 2 hour Safety documentation
(side rails, etc.) required
Safety task removed; now included in
assessment. Other documentation as
needed (chart by exception).
Results: Elimination of redundant and unnecessary
documentation yielded an overall reduction of
10% or 12 tasks per patient per nurse per day.
Frequent AC4 updates; as many
as 5 updates within 8 daysQuarterly updates
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Clinical Documentation Environment – 1 Year Later
Improve Flow - Removal of redundant fields
Policy Change - Removal of Q2 Hr Frequent Nursing
Interventions (FNI)
54% spend less time documenting
56% chart more effectively
Quarterly bundles
81% are informed of updates and changes
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6 out of 10 nurses noted an increase in overall
satisfaction since the implementation of improvements
Key Success Metrics
Frequency of documentation
Why so often?
Amount of documentation
Why so much?
Efficiency of charting in the
system
Why so many clicks & screens?
Training and Education
Why so many changes &
updates?
AC4 audit of number of repetitive
tasks per patient
Track number of changes over time,
monitor learning management
system for compliance in
completing online education
Survey clinical users following each
bundle release
Evaluate with bundle
implementation
Implemented reporting format with nursing leadership and AC4 PIT Crew
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Closing the Loop
Frequent follow-up with the recommendation action
owners
Monthly report to CNO Council
Maintain SharePoint link with documents and follow-up
Ongoing dialogue with AC4 PIT Crew and super users
Front-line advocates for change
Sharing of best practices
Setting priorities
Evaluating ideas for next steps
Implementation approaches
Vetting effectiveness
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Lessons LearnedCritical Success Factors
Constant communication with all levels
Regular feedback loops and touch points
VOC from front-line through CNO’s
Partnership between ISD, Nursing Leadership, and Six
Sigma
“Moving on from here” mentality;
no blame for past mistakes
Involve front-line staff and
informal nursing leaders
Phased approach and quick
wins
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Questions?