Electronic Health Records: Proactive Risk Assessment for Hospitals Most healthcare organizations are moving to an electronic health record (EHR), and for good reason. With the right EHR process in place organizations can streamline healthcare services to drive operational efficiency. The EHR is also designed to reduce errors and provide safer care. Yet, far too often […]
Most healthcare organizations are moving to an electronic health record (EHR), and for good reason. With the right EHR process in place organizations can streamline healthcare services to drive operational efficiency. The EHR is also designed to reduce errors and provide safer care.
Yet, far too often when an organization embarks on the journey to implement electronic health records, responsibilities can be shifted or forgotten. Without the involvement of key stakeholders, staff often need to create workarounds that create risk to patient safety. Front line staff should be included to ensure processes are developed for ease and efficiency of use.
Ehr Use Results In Improved Patient Safety And Quality Of Care
Digital transformations are challenging in every industry and take on various forms, like customer experience, quality, workflow and efficiency. Hospitals have the added layer to factor into any organizational change – the critical element of patient safety.
It can be helpful to look at this journey across three levels of your organization: your initiatives, your leadership, and your organization’s vision. Each level brings a different lens to the potential risks that could occur when key stakeholders are not involved in the development of the EHR. Initiatives should include regulatory compliance, patient and staff experience, availability of resources (human, financial, and physical), and streamlined communication. Leadership should be engaged in assessing whether any recommended practice affects the healthcare organization’s ability to deliver safe, effective, and high-quality care. The organization’s mission, vision, and values should be incorporated into the culture that fosters safety as a priority for everyone who works in the hospital.
Organizations may think their electronic health record process is designed to minimize potential harm that patients could receive, only to be disappointed upon learning they have unidentified safety risks when a patient safety event happens or during an accreditation survey. To mitigate safety hazards and known risks, we recommend proactive risk assessments that address specific areas that may require adjustment of the EHR configuration parameters.
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The first major risk area is that the actual systems and processes in place to capture EHRs do not match the organization’s policy requirements. It is not a coincidence that the first thing surveyors do when they come to your organization is look through a list of documents you have prepared that include numerous policies. They want to know what the organization requires staff to do and document. Then they want to ensure staff are incorporating policy requirements into their workflow and not creating workarounds.
For instance, if an order is placed to titrate a drip to keep the Richmond Agitation-Sedation Scale (RASS) at a -2, the survey team will look for the documentation that supports the titration order. Far too often, surveyors find that key elements such as RASS are either not built into the system at all for the nurse to document, or nurses are expected to navigate to another screen to document this component. Having the nurse toggle between multiple screens can be a risk to patient safety. There is also an increased probability that the nurse will assess the scale but not remember to document it because the documentation is not located in a place that mimics the required workflow.
The second common risk to patient safety has to do with variation. Have you ever heard the old saying, variation is the enemy? During the survey process, it can be. Accrediting agencies do not require or recommend a specific format for health records. At the time of survey, health records are evaluated on consent based on the defined standards of the accrediting agency. However, when surveyors review an EHR, they are looking for consistency in documentation across the organization. If each department has its own approach to documenting an EHR, it can be a red flag for surveyors.
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One example could be the documentation for a time out. In one area of your organization, a nurse might record a time out as “correct patient, correct site, correct procedure.” Yet in another department, a nurse might record it as “time out completed.” A surveyor will notice the difference in documentation styles and refer to your organization’s policy to see which is correct.
Standardization across all areas of your organization ensures that required elements are made clear to staff and practitioners. Wrong-site, wrong-patient, and wrong-procedure surgery continues to be one of the most frequently reported events voluntarily reported to the Joint Commission, with 98 reported events in 2018. High-reliability organizations reduce the variability within their documentation to achieve zero harm.
Even though you may have identified and addressed risk areas and hazards, your organization’s EHR process is only as good as your staff’s ability to confidently navigate that process. Patient care can be impacted if nurses forget crucial steps due to uncertainty or missing key details from patients during documentation. Significant value is added (such as strengthened workflows) in getting others involved during the risk assessment.
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Keep in mind that during a survey your staff will be reviewing health records retrospectively with the surveyor in some cases. This can be very difficult if staff are not used to looking at a record in this environment. Staff might also be uncomfortable navigating the record if the surveyors requested item was documented in a different department. The survey process will go smoother if staff are able to navigate the record with confidence and ease. Consider nominating someone on staff to be a “super user, ” available to assist staff with navigating the record to locate surveyor requested information.
Is your electronic health record process built to minimize safety risks and ensure compliance with required documentation elements? The best way to test your organization’s readiness is to pull records throughout the organization on various topics. For instance, if invasive procedures are performed in numerous areas, then pull one from each area and look for instances when staff have not documented according to the policy, and for variation in charting practices.
If you notice you have a variation, we can help you fine-tune your EHR to ensure it is driving continuous performance improvement. We will partner with you to support your staff along that journey so that your organization thrives without us. Our goal is the same as yours: to provide safe, quality care for the people who matter most—your patients.
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To discuss how TiER1 Healthcare can help your team form a complete approach to providing a safe and effective care environment, contact us at (800) 241-0142 or healthcare@-staging.qrvschg3-liquidwebsites.com for a consultation.
TiER1 Healthcare consultants help hospitals, health systems, and other healthcare organizations improve performance from within. As part of TiER1 Performance, we partner with healthcare executives who want to be better and do better. We identify obstacles (like risks to patient safety or extended lengths of stay), and then we overcome them. We start where our clients need us with the data they have on hand, using tried-and-true solutions for achieving operational excellence and patient safety.
Our goal in this work is to move away from a sole focus on “what you have to fix” and move toward “how might we design a sustainable culture of patient safety.”As the old saying goes, “practice makes perfect, and in no place is that phrase more important than a profession in which it's your job to save people's lives.
Electronic Health Records Help Improve Care Outcomes And Reduce Costs
So when it comes to training the next generation of nurses, an increasing number of nursing schools are looking at how an educational EHR improves can patient outcomes.
When nurses and other health care providers have access tocomplete and accurate information, patients receive better medical care and overall outcomes improve.Electronic health records(EHRs) can improve the ability to diagnose diseases and reduce-even prevent-medical errors. Accurate records can literally mean the difference between life or death in some cases.
With EHRs, nurses can enter, retrieve, and update individual patient records. Plus, the organizations that utilize these EHRs receive helpful tools, such as reminders and alarms, to help automate processes for improved clinical accuracy and outcomes. Electronic documentation with these systems can help decrease documentation deficiencies and errors, as well, since an EHR system's prompts remind a nurse to chart certain important aspects of the patient's case.
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Dr. Christopher Tashjian, a family medicine practitioner in Ellsworth, Wis., was visiting Estonia in 2011 when he got a call from a patient who needed a refill on blood pressure medications. Dr. Tashjian was able to access his patient's records using a mobile connection to his EHR, and called in a refill for the patient. He specifically sites the EHR's summary abilities as being extremely useful in improving patient outcomes.
“All their important health information is captured in the summary. They can take a print out of the summary to another doctor, which is also a helpful safety measure, Dr. Tashjian explained. “In addition to helping providers offer quality health care, the summaries allow patients to better remember what
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