Katherine Howell shares leadership tactics and lessons learned to remove redundant documentation structures and processes from our frontline nurses.
Documentation burden is a barrier to the quadruple aim of improving health, patient experience, efficiency, and clinician wellbeing. Last year this 12-hospital system eliminated 170 million clicks and returned 18 minutes per shift to the bedside, doubling satisfaction with flowsheets. Executive leadership is essential, requiring complex organizational negotiation among competing needs in the context of the myth “not documented, not done.” Presenters will detail their leadership tactics and share hard-won lessons learned.
Selected Podcast
Reducing Documentation Burden to Return Joy to Nursing
Featuring:
Katherine Howell
Katherine Howell is the Chief Nurse Executive at UCHealth. Transcription:
Bill Klaproth: (Host) So, how do you reduce documentation burden to return joy to nursing? Well, let's find out with Katherine Howell, chief nurse executive at UC Health. This is Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership. I'm Bill Klaproth. Katherine, thank you so much for your time, it is great to talk with you. So why is documentation burden a barrier to the quadruple aim of improving health, patient experience, efficiency, and clinician wellbeing?
Katherine Howell: (Guest) Well, the number one reason is removing redundant, not helpful structures and processes from our frontline nurses. They need to focus on the patient, they need to make sure they're documenting meaningful information that really helps effects the outcomes of care. So by us, not addressing documentation burden, we are giving them down value-added work that really does not even help the patient or improve outcomes.
Host: And I imagine they appreciate having to do less documentation.
Katherine: Most of the time, occasionally nurses like to hold on to some tried and true beliefs, but we really have worked through the process and structure and it's taken some culture changing to help them to understand what really needs to be documented and what needs to be documented needs to tell the patient's story. And we also helped relieve them of some of their, beliefs regarding regulatory requirements or risks related documentation. So those were important to target as we really moved ahead with this culture change.
Host: So speaking of this culture change, how did you solve this problem, what changes did you make?
Katherine: Well, it first started with really commissioning the work through the chief nursing officer council. We have a nursing strategic plan for UC Health that we update annually and we have put that as a high priority on our plan. So that was number one, we had executive-level sponsorship and then number two, I'm setting to putting together the right structure to make this happen. So put together a group of front-line staff nurses from a variety of specialties and from each of our hospitals throughout our system, to actually weigh in on these issues. But probably the most helpful thing we did is develop a group called guardrails. This is where we had a risk expert, a legal expert, a regulatory expert, et cetera. So when our nurses brought up their misgivings or, we possibly had a belief that no longer is true. From a regulatory perspective, they were able to clear it up right at that time. And then we also had to have, and it was probably the first year, some agreement where we developed really some guiding principles as rules of the road, and that was important to agree upon. And then the second piece we did is, develop criteria to keep an element, not to remove it. We really looked at most elements and say, why do we have all these rows of documentation? Let's develop criteria to keep elements of documentation. So it really changed the way we thought about what we are doing. So putting that guardrails group together with the subject matter experts and then a really good expert facilitator, to really start getting this work done really has helped optimize what we're doing.
Host: Wow, a really comprehensive plan. So tell us what were the results?
Katherine: After the first-year work and we just worked on the nursing flow sheet for med surge, that was the first one to tackle. We saved 18 minutes of time per nurse, in documentation per shift, which was quite significant. And I believe, and I don't want to misquote the number of actual clicks we decreased, but it was hundreds of clicks. And we also did a pre and post measurement of the nurse's satisfaction with the flowsheet, and we had a significantly improved outcome from previous to post-implementation. So after that initial success, and then we really, really try to communicate it widely. After that success the subsequent years and we've been on this is our third year, so we've still got a long way to go. After that subsequent first year, there was a lot of interest and a lot of other nurses who wanted to join the effort. Now our challenge has been to keep the group large enough, but small enough to get something done. And, yeah, that's been very helpful, but I think probably foundationally to get those outcomes agreeing upon guiding principles, with not only our frontline nurses, but those key individuals in our guardrails group was key. And then really changing our mindset about why we document. And again, it's to tell the story about the patient to improve patient outcomes.
Host: So 18 minutes that may not sound like a lot, but you add that up day after day, week after week. Oh my gosh. That's huge.
Katherine: We valued it to be approximately $2 million. When you look at how many nurses we have and how many days of the year, it probably came to $2 million in what we had is non-value-added work. So we could, again, bring joy back to the bedside.
Host: I love that. So why is executive leadership so essential in a project like this?
Katherine: Number one, they needed the resources and support. Resources to actually get frontline nurses and to pay them to be part of this group. So we paid their time. Number two, to make sure that we had our informatics support so our clinical informaticist and our IT architects and designers available and participating in this group and making this a priority, because any time you're dealing with an electronic medical record, there are always competing priorities and changes that need to be done. So we had to put this as a strategic priority, so it gets the attention and the resources it needed to accomplish this work. If we wouldn't have done that, we would have been fighting for time and I just don't think we'd accomplish what we'd accomplished. It might've taken us three years to get done what we did the first year.
Host: So looking back, can you detail your leadership tactics and share the lessons that you learned?
Katherine: I think the first is, number one, getting your executives to champion the effort. So we did that again through the strategic planning process for UC Health and made it a priority. And it was a priority of the chief nurse executive, myself. And then, number two, partner with our CIO and the whole clinical informatics team to develop this structure. And the structure, it took us some time, but it was well worth the time we had to take to get that right. Because if we would have just barreled in and started making changes without sitting back and thinking about the process. Because how our EMR was developed, approximately eight years ago, our health system was probably half the size and it was a lot of just converting flow sheets into an electronic format without really thinking about, or being as sophisticated as we need to about really workflows and processes within an EMR. We still have a lot of cleanup. And again, the cleanup really is along following the patient care process. So if we want to put that structure in, to make this happen, we possibly would not have gotten the same results and continue to have to refine that and remind people of that. And then when people want to add to documentation, that has to go to our project joy group, to actually, get documentation added because some group may not realize this and they're coming and requesting documentation, and it may have been something we already pulled out. So we use it as a guard rail so that we don't get documentation creep that enters back in.
Host: Well, this is going to be a dynamite session. You're really going to cover this more in-depth, is that right, Katherine?
Katherine: That's absolutely right. And I'll be sharing the virtual podium, with our leader. She's a clinical informaticist, plus she's a doctorally prepared nurse who really helped lead this effort. And so she'll be sharing a lot of the in-depth side of things and I'll be sharing more of the system perspective, and outcomes, so we really look forward to the conversation
Host: It's going to be a great session, how to reduce documentation burden to return joy to nursing. Catherine, thank you so much for your time. This has really been interesting. Thanks again.
Katherine: You are most welcome, thank you.
Host: That's Katherine Howell. And for more information, please visit AONL.org. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Today in Nursing Leadership. Thanks for listening.
Bill Klaproth: (Host) So, how do you reduce documentation burden to return joy to nursing? Well, let's find out with Katherine Howell, chief nurse executive at UC Health. This is Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership. I'm Bill Klaproth. Katherine, thank you so much for your time, it is great to talk with you. So why is documentation burden a barrier to the quadruple aim of improving health, patient experience, efficiency, and clinician wellbeing?
Katherine Howell: (Guest) Well, the number one reason is removing redundant, not helpful structures and processes from our frontline nurses. They need to focus on the patient, they need to make sure they're documenting meaningful information that really helps effects the outcomes of care. So by us, not addressing documentation burden, we are giving them down value-added work that really does not even help the patient or improve outcomes.
Host: And I imagine they appreciate having to do less documentation.
Katherine: Most of the time, occasionally nurses like to hold on to some tried and true beliefs, but we really have worked through the process and structure and it's taken some culture changing to help them to understand what really needs to be documented and what needs to be documented needs to tell the patient's story. And we also helped relieve them of some of their, beliefs regarding regulatory requirements or risks related documentation. So those were important to target as we really moved ahead with this culture change.
Host: So speaking of this culture change, how did you solve this problem, what changes did you make?
Katherine: Well, it first started with really commissioning the work through the chief nursing officer council. We have a nursing strategic plan for UC Health that we update annually and we have put that as a high priority on our plan. So that was number one, we had executive-level sponsorship and then number two, I'm setting to putting together the right structure to make this happen. So put together a group of front-line staff nurses from a variety of specialties and from each of our hospitals throughout our system, to actually weigh in on these issues. But probably the most helpful thing we did is develop a group called guardrails. This is where we had a risk expert, a legal expert, a regulatory expert, et cetera. So when our nurses brought up their misgivings or, we possibly had a belief that no longer is true. From a regulatory perspective, they were able to clear it up right at that time. And then we also had to have, and it was probably the first year, some agreement where we developed really some guiding principles as rules of the road, and that was important to agree upon. And then the second piece we did is, develop criteria to keep an element, not to remove it. We really looked at most elements and say, why do we have all these rows of documentation? Let's develop criteria to keep elements of documentation. So it really changed the way we thought about what we are doing. So putting that guardrails group together with the subject matter experts and then a really good expert facilitator, to really start getting this work done really has helped optimize what we're doing.
Host: Wow, a really comprehensive plan. So tell us what were the results?
Katherine: After the first-year work and we just worked on the nursing flow sheet for med surge, that was the first one to tackle. We saved 18 minutes of time per nurse, in documentation per shift, which was quite significant. And I believe, and I don't want to misquote the number of actual clicks we decreased, but it was hundreds of clicks. And we also did a pre and post measurement of the nurse's satisfaction with the flowsheet, and we had a significantly improved outcome from previous to post-implementation. So after that initial success, and then we really, really try to communicate it widely. After that success the subsequent years and we've been on this is our third year, so we've still got a long way to go. After that subsequent first year, there was a lot of interest and a lot of other nurses who wanted to join the effort. Now our challenge has been to keep the group large enough, but small enough to get something done. And, yeah, that's been very helpful, but I think probably foundationally to get those outcomes agreeing upon guiding principles, with not only our frontline nurses, but those key individuals in our guardrails group was key. And then really changing our mindset about why we document. And again, it's to tell the story about the patient to improve patient outcomes.
Host: So 18 minutes that may not sound like a lot, but you add that up day after day, week after week. Oh my gosh. That's huge.
Katherine: We valued it to be approximately $2 million. When you look at how many nurses we have and how many days of the year, it probably came to $2 million in what we had is non-value-added work. So we could, again, bring joy back to the bedside.
Host: I love that. So why is executive leadership so essential in a project like this?
Katherine: Number one, they needed the resources and support. Resources to actually get frontline nurses and to pay them to be part of this group. So we paid their time. Number two, to make sure that we had our informatics support so our clinical informaticist and our IT architects and designers available and participating in this group and making this a priority, because any time you're dealing with an electronic medical record, there are always competing priorities and changes that need to be done. So we had to put this as a strategic priority, so it gets the attention and the resources it needed to accomplish this work. If we wouldn't have done that, we would have been fighting for time and I just don't think we'd accomplish what we'd accomplished. It might've taken us three years to get done what we did the first year.
Host: So looking back, can you detail your leadership tactics and share the lessons that you learned?
Katherine: I think the first is, number one, getting your executives to champion the effort. So we did that again through the strategic planning process for UC Health and made it a priority. And it was a priority of the chief nurse executive, myself. And then, number two, partner with our CIO and the whole clinical informatics team to develop this structure. And the structure, it took us some time, but it was well worth the time we had to take to get that right. Because if we would have just barreled in and started making changes without sitting back and thinking about the process. Because how our EMR was developed, approximately eight years ago, our health system was probably half the size and it was a lot of just converting flow sheets into an electronic format without really thinking about, or being as sophisticated as we need to about really workflows and processes within an EMR. We still have a lot of cleanup. And again, the cleanup really is along following the patient care process. So if we want to put that structure in, to make this happen, we possibly would not have gotten the same results and continue to have to refine that and remind people of that. And then when people want to add to documentation, that has to go to our project joy group, to actually, get documentation added because some group may not realize this and they're coming and requesting documentation, and it may have been something we already pulled out. So we use it as a guard rail so that we don't get documentation creep that enters back in.
Host: Well, this is going to be a dynamite session. You're really going to cover this more in-depth, is that right, Katherine?
Katherine: That's absolutely right. And I'll be sharing the virtual podium, with our leader. She's a clinical informaticist, plus she's a doctorally prepared nurse who really helped lead this effort. And so she'll be sharing a lot of the in-depth side of things and I'll be sharing more of the system perspective, and outcomes, so we really look forward to the conversation
Host: It's going to be a great session, how to reduce documentation burden to return joy to nursing. Catherine, thank you so much for your time. This has really been interesting. Thanks again.
Katherine: You are most welcome, thank you.
Host: That's Katherine Howell. And for more information, please visit AONL.org. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Today in Nursing Leadership. Thanks for listening.