“Electronic Charting: The ‘Spring’ of a New Documentation Era”

1. “Electronic Charting: The ‘Spring’ of a New Documentation Era” Steve Biondi, M.S., RN Wendy Ehnis, M.S.N., RN Rita Roedel, M.S., RN Extendicare Health Services, Inc.

2. Spring Thoughts • In like a Lion out like a Lamb • Spring Forward • Spring Training • Spring Fever

3. Focal Areas • Why • Pilot Experience • Front Line Staff Characteristics • Documentation Elements • System Design • Operational Considerations • Teaching Strategies • Outcomes

4. Background Why • Wanted to improve resident care • Real time documentation • Up to the minute compliance monitoring • Standardization of charting • Eliminate illegible handwriting • Wanted to improve manual system • Incomplete • Labor intensive • Data analysis was difficult • Trending was cumbersome • People at all organizational levels had positive experience with electronic CNA charting system

5. Background Outcomes • Easy to learn • Flexible as documentation parameters change • Easy to use

6. Background Pilot • Facility proven track record • Stable Administrator, DON, MDS Coordinator • Good survey history • Supportive of corporate systems • Adapts well to change • Five geographically diverse locations began in April 2006 • Four basic clinical parameters chosen • Within 6 months decided to implement corporate wide

7. “The worlds favorite season is the spring. All things seem possible.”--Edwin Way Teale

8. Front Line Staff Characteristics • Visual Learners • Bright colors • Visual Cues • Emphasize key concepts • Native Language • Workforce diversity • Reading Skills • Simple terms • Reinforce with graphics

9. Front Line Staff As Adult Learners • Need to see value of system • Need to see practicality of system • Need to be shown respect for prior life and work experiences

10. Documentation Elements Why Chosen • Based on elements most frequently charted by CNAs • Encompass some of more prominent QI/QM and RUG elements that are critical to the resident POC

11. DocumentationImplementation Elements

12. Documentation Elements • Mood (E) • 16 elements • Frequency • Up to 5 days • 6 to 7 days • Behavior (E) • 6 elements • Frequency • 1 to 3 days • 4 to 6 days • Daily

13. Documentation Elements • Mood (E)/Behavior (E) • Consider alterability • System tracks interventions tried • Effectiveness of interventions

14. Documentation Elements • ADLs (G) • 11 Elements • Self performance and support provided • Focus “late loss” because of RUG and QI/QM implications • Bed mobility • Transfer • Eating • Toilet Use

15. Documentation Elements • Continence (H) • Bowel/Bladder • Self control categories • Scheduled toileting • Bladder retraining

16. Documentation Elements • Weight Loss (K) • 5% 30 days • 10% 180 days • System has flexibility for percentages and time parameters • Nutritional Approaches (K) • Considers IV, tube feeding • Tracking of food and fluid intake

17. Documentation Elements Added • Restorative Nursing (P) • Number of minutes/24 hours • Number of days > 15 minutes/24 hours • Staff consistently communicate they want documentation on elements added!!

18. “An optimist is the human personification of spring.”--Susan J. Bissonette

19. Documentation System Design • Easy to learn • Must be able to de-”CMSize” language (i.e. support provided of 1 person coded 2 on MDS) • Get up to speed quickly • Visual • Images/graphics reinforce key concepts • Basic reading skills • Target was 6th – 8th grade level • Time sensitive • Entries date/time stamped • Prohibit charting until logical (i.e. unable to document lunch consumption until time appropriate)

20. Documentation System Design (cont.) • Independent • Avoid “copy cat” charting • Staff working smarter • “Chart as you go” • Alerts staff to situations requiring attention • No bm in last 9 shifts • Less than 1000 cc fluid intake over 24 hours • Acknowledge job well done • Real time feedback • Able to pinpoint shift, location, individual employee performance

22. Operational Considerations Security access • Based on function at building • CNA kiosk for data entry • Licensed staff care alert reports • HIPAA compliance • Used unique resident demographic information • Reinforced confidentiality @ kiosks • System backup • Nightly back-up at off-site date center • Home like environment • Aquarium screen saver

23. “Spring is when you feel like whistling even with a shoe full of slush.”-- Doug Larson

24. Flexible Teaching Strategies • Classroom • Initial rollout training • Short session • One – to – One • Kiosk for data entry • Work station for report overviews • Used tell-show-do approach • Chewable bits • ADL and Mood/Behavior coding week before • Education Resource Binder • Mood/Behavior Bingo • ADL cards describing scenario • Real time resident function/behavior

25. Flexible Teaching Strategies(cont.) • Visual Aids • Quick reference laminates at Kiosks • Story boards • System has additional help screens • Key Points • 75% adults retain more information from sight education than other senses • 72 hours is key for retention of learning • Went live within 24 hours

26. Outcomes • Completeness of documentation • Corporate standard > 95% • Consider • 100 documentation elements • 100 bed SNF • 10,000 documentation elements/24 hours @ 95 compliance is 9500 • Monitor resident status • Care alert reports • Enhanced communication • Messaging feature • Catch staff doing it right • Individual staff, shift, unit • Capture resident acuity • Fewer “holes” • Multiple entries • Fire story

27. Spring is natures way of saying “Let’s Party!”--Robin Williams