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Running head: WORKFLOW PROJECT MANAGEMENT

Workflow Project Management


Santa Winkler
Molloy College
Nursing 544-01

WORKFLOW PROJECT MANAGEMENT


Abstract

This paper will identify a workflow and systems challenge at Queens Hospital Center. A
proposal of an information system that will remedy and or improve the current workflow will be
presented. This author will analyze the current state of the workflow systems issues, discuss the
challenges that is presented by the employees / end users. In addition, this author will propose
an innovative information system that will amend the workflow difficulties that was presented.
An implementation plan will be discussed as well as a training plan, Also, a go live strategy and
a support system that will assist with the sustainment of the workflow project will be discussed.
Introduction
The admission, transfer and discharge system process that is currently being utilized at
Queens hospital Centers Behavioral Health Department is complex and often increases patients
length of stay. Most importantly there has been an increase in medication errors due to gaps in
the system. In addition, the current process has a lot of room for improvement. The workflow
system that is currently implemented is disliked by many interdisciplinary team members.
The hospital has a comprehensive psychiatric emergency program (CPEP) that provides
psychiatric assessment and stabilization to patients who are exhibiting acute psychiatric
symptoms. The patients are brought to the CPEP via emergency medical services (EMS), NYPD
or by family. Its also likely that an individual who is well educated about their illness and has
insight will walk to the CPEP for an evaluation. Upon arrival to the hospital the patient is given
a legal status. A patient who voluntarily walks in and requests a psychiatric evaluation is given a
voluntary status. The involuntary patient who was brought in by NYPD, EMS or even a family
member is classified as a 9:39. This simply means that the person is involuntarily being assessed

WORKFLOW PROJECT MANAGEMENT


/ evaluated for stabilization. A two physician certification (2PC) means two physicians must
evaluate a person and certify that further stabilization is required. Once admitted to CPEP
patients can stay there for up to three days by law. Afterwards, the patient is either discharged
from the CPEP or admitted to inpatient services.
Current State
The assessment process begins with the nurses assessment by which the nurse gathers
information from the patient or family member about the reason for the visit. A detailed
psychiatric and medical history is collected, emergency contact information is filed, medication
reconciliation and history of medication / treatment compliance is recorded. Patients property
is sorted, and a patient search is conducted. This search is to ensure safety of the patient and
staff while on a psychiatric unit. A unit clerk is present during the nurses assessment. Their duty
is to document required information for insurance purposes such as social security numbers,
medical / insurance numbers. This information is mandatory for financial reimbursement.
During the patients stay in the CPEP, a psycho- social assessment is conducted by a
social worker. The Social Workers role is to ensure a safe discharge disposition for patients.
However, Social workers often face barriers. The patient is not always willing to share
information about themselves. Clinical manifestations of their illness might cause them to
become paranoid or acutely psychotic to the point where they are not able to process any
information. Homelessness is another barrier to a safe and timely discharge.
The physicians assessment is conducted after the nurses assessment. During that time
the patient has already been in the CPEP for 1-3 hours. The doctor evaluates the patients

WORKFLOW PROJECT MANAGEMENT


presenting symptoms, history, medication and illness history. The physician gathers information
subjectively and objectively, thereby determining the necessity for hospitalization.
All assessment are partially documented in an electronic health record system and
partially on paper. The current health system being utilized is the Quadra- Med electronic health
record System. The Quadra -Med system was implemented at Queens Hospital Center to
improve documentation and information sharing. The intended demographic for the Quadra
-Med system are Nurses, Nursing assistants, Physicians, Physicians assistants, Respiratory
therapist and their assistants, Occupational therapists, Physical therapists and their assistants,
Pharmacist, and Dieticians.
Nurses use the Quadra-Med for charting patient progress, reviewing Physician orders,
documenting patient vital signs, documenting medication administration and medication refusals.
Quadra-Med is also used in conjunction with medication bar coding. The bar code feature is used
to enhance patient safety. Nurses are extremely busy and their workdays are unpredictable. Any
event can happen at any given minute. A nurses busy day puts patients at risk for harm. Also, it
opens the door for miscommunication and false documentation. Nursing assistant use the
Quadra-Med system for documentation of vital signs, intake and outputs, and activities of daily
living such as eating, bathing, ambulation, and toileting.
After a three day stay in the CPEP the ER nurse is ready to give repot to the inpatient
nurse. This process can take a while. Inpatient psychiatric nurses are not always willing to get
report promptly. The inpatient nurses complain that the ED nurses call to give report during shift
change or during medication administration time. The CPEP nurses have to seek the assistance
of administrators to complete the report and transfer process.

WORKFLOW PROJECT MANAGEMENT


Once the patient arrives to the inpatient unit. A nurses assessment is conducted within 8
hours of the admission time. The physician assessment is conducted within 24 hours of the
patient stay. A Psych-social assessment is conducted within 72 hours. Case management and
Social Workers are not on duty during the weekends in psychiatry. Therefore, if a patient is
admitted to on a Friday, their psycho-social and insurance verification cant be determined.
(Please see the attached swim lanes diagram to better understand the RN workflow).
System Issues or Problem
The Quadra-Med electronic health systems was implemented to improve patient care, decrease
errors and improve workflow such as, documentation, communication and user flexibility. At
Queens Hospital Center Quadra-Med is used in a variety of departments and the electronic
system address each departments specific needs. In psychiatry Quadra-Med is partly used. The
electronic system differs from in-patient and the psychiatric emergency department (ED). This is
a major issue for many nurses. Last year there were several medication errors that occurred as a
result of a nurse not being able to access the ED Quadra-Med system. In one instance a nurse
was floated to the emergency department and because the Quadra-Med system differed the nurse
wasnt able to log on to Quadra-Med. She had to contact the information technology technician
to assist her with transferring her login information to the ED Quadra-Med system. The entire
process took approximately three hours. When the nurse was finally able to log on to the ED
Quadra-Med system. She noticed that there were two stat medication orders that were ordered
two hours prior. Another gap in the Quadra-Med system is the downtime feature. DART is the
system that is used at Acme medical Center. This particular system allows the nurse to view
standing orders. However, the nurses cannot document in the DART system. Also, clinicians
have to utilize paper order forms if they want to prescribe something for a patient during a

WORKFLOW PROJECT MANAGEMENT


downtime. This is a challenge for the nurses and the clinicians as well. The design of the DART
software system allows the nurses to conduct patient care, however, the basic function of
documentation is absent. Another major gap in the psychiatric Quadra-Med system is the
documentation of progress notes. Because there is very limited documentation of progress notes
in the system, in most cases the Nurses are documenting the progress notes in the paper chart.
This information is usually only viewed by the Nurses that work on the floor and those providers
that have the time to sit down and read the chart. In most cases the providers are viewing patient
information online and using that information to order treatments medications discharges
admissions or transfers. If a provider had any questions or concerns about the nurses
documentation he/she would have to call the floor directly and speak directly to the Nurse. This
is a waste of time and resources. If Quadra-Med had a feature where the nurses could write a
comprehensive note within the system then providers would have real time information on the
patient that would assist them during clinical decisions. This would be a great improvement in
the continuity of patient care overall as nursing documentation is used by many disciplines such
as social work and case management. Documentation online would also solve any issues with
legibility as all documentation would be clear. To the nurse documentation is vital in healthcare.
The nurses of the psychiatry department want solutions to all of these identified
workflow barriers that complicates their day and inhibit them from providing safe quality care to
patients. In addition, the interdisciplinary team wants to be part of the decision making to ensure
that the new system will meet the needs of every team member.

Proposed Innovation

WORKFLOW PROJECT MANAGEMENT


The proposed Innovative system that will amend the identified workflow difficulties in the ED
and patient units. This system will be user friendly, comprehensive, and will have an
interdisciplinary focus. The proposed electronic health system will be state of the art and
improve the current process tremendously. The system will provide a seamless process that will
increases staff and patient satisfaction, comply with CMS / Meaningful use requirements,
increase worker productivity, decrease patient dwell time in the CPEP / ED, decrease patient
length of stay while providing quality care and maintain patient safety.
This system will have 3 main features. First the ED Nurses will be given the ability to
use the Electronic Medical record to give report to the Nurses working on the impatient
psychiatric units. This report will be in the form of an SBAR to ensure that the report is through
and it meets the current standards used by the hospital. Once the Nurses enter report in the
system, the receiving Nurses and as well as the clerk on duty will receive an alert on their
computer screen to remind them to review the report. For transfer reports, the system will send
an alert to the receiving RNs as well.
Communication is an important part of patient care. If communication is unclear or
misinterpreted, errors can occur. That is why it is imperative that nurses receive accurate and
precise reports. The most commonly used nurse report format is the Situation, background,
assessment, and recommendation report better known as SBAR. The SBAR is powerful tool
that is used to improve the effectiveness of communication between individuals. It is easy to use
and can help staff learn key components needed to send a complete message (Labson, M 2015).

Secondly the Nurses will have access to a intercom system which will be available to
communicate among team members for report or for real time notification of new orders or

WORKFLOW PROJECT MANAGEMENT


change in orders. Diagnostic testing referrals or other consultations can be communicated via the
portable intercom system.
Lastly, the new system will interface with a display board in the CPEP / ED. This system
will display unit patient census, the members of the treatment team, and the transfer status of the
patient as well as the patient length of stay. This electronic board will be visible to providers,
nurses, and ancillary staff involved in the patients care.
With the proposed new system. Patients will enter the CPEP / ED. Their names will be
entered into the new system. If the patient had prior hospitalizations in the hospital or another
hospital the information will be retrieved because the system will have the ability to interfaces
with other systems need for admission.
After the patients information is entered in the new system the CPEP nurse will complete
the SBAR tool along with their other assessments. After the nurses saves and complete their
assessments, a notification will automatically be sent to the assigned provider and social worker
in that department. The notification will alert the provider and social worker about the new
patient that has just been triaged and prompt the MD to complete the provider assessment. The
social worker will also be prompted by the system to complete a psycho-social assessment.
These features of the new system will save time and provide care to the patient promptly.
The ED nurse will pick up the order for transfer and input the patient information into the
electronic display board. The nurse will then call the unit to give report. If the ED nurse is
unable to give report which is a major problem in the current state, The ED nurse must document
the SBAR report in the system which will send an alert to the inpatient nurse, and nurse manager.
The inpatient unit clerk will also be notified so a bed can be assigned. The clerk must work
collaboratively with the admitting office.

WORKFLOW PROJECT MANAGEMENT


The inpatient nurse will get the report electronically and or verbally on the phone. Patient
transport team will be scheduled through the new system. The patient will then be transported to
the unit. The unit nurse will greet and assess the patient. Providers will then assess the patient.
This workflow will improve communication and decrease frustration during the ED to in- patient
report workflow. Employee and patient experience will be a better one. The budget for the new
electronic health system will cost approximately $200,000. The time line for purchasing,
planning, educating and implementing will be one year and education will be conducted for six
months.
Proposed Implementation
The implementation process of the new system require a tremendous amount of planning.
According to Saba & McCormick, 2011) There are five phases of project management which
includes fourteen implementation steps. Phase one is the initiation phase. This phase includes
steps one four of the implementation process. Project scope, hardware, application
administration and training. The second phase is planning. Planning includes steps five through
seven which involve planning. Execute and control phases includes live operation testing, unit
testing and end user training. Finally, the fifth phase is the close phase, which is the post
evaluation implementation.
This process will require the expertise of a committee that consist of staff nurses,
nursing educators, information technologists, nurse informaticists, and other
members of the interdisciplinary team who serves as subject matter experts
in their area. The subject matter experts will help to individualize and
customize the system to meet their needs. The goals for implementation of
this new system is training users, testing the system, and the Go live phase.

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Training for the new system will require coordination on multiple levels.
Unit managers have to coordinate staff schedules. The staff that volunteer
to be super users must be committed to the success of the new system.
Super users must be exempt from patient care during the Go live phase. As
illustrated on the attached Gantt chart, Training for nurses and providers will
commence on July 1, 2016 and end on July 31, 2016. This is a robust training
schedule that will be demanding. Training for administrators will commence
on July 1, 2016 and end the first week of September 2016. The training for
administration is longer due to the demanding nature of their roles.
Administrators ensure the implementation process is on target by facilitating
meetings to gather input about progress made. The current state of the
project will be presented to the executive board members. They are also
responsible for ensuring that clinical management are all involved and
supportive to the staff.

There will be a overlap in the training schedule.

However, the overlap will not impede patient care.


Hospital staffing during the implementation phase will be a barrier.
Therefore, prior to training. Hospital executive should plan for supplemental
staffing. Agency workers, Overtime, and per diem staff would be
incorporated as staff relief. Another barrier is locating a training center that
is large enough to accommodate hundreds of employees.
System testing will start in July 2016 and end in September 2016. The
testing phase is a process that will identify systems errors, workflow glitches
and allow the staff to acclimate themselves to the new system. Specific

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systems testing in the CPEP / ED

will occur in August 2016 the last week

of September 2016. The Inpatient unit systems testing will be a longer time
frame due to the number of staff that will require training. The inpatient
area testing will start in August 2016 until October 2016. The inpatient
workflow is more complex than CPEP therefore there are more system
features for the inpatient units. Staff will require multiple levels of training.
Training sessions will be eight hours four days a week in order to ensure
comprehension and knowledge of the system. Staff will have to return
demonstrate features of the system, they will have a verbal and written post
training exam.
The Go live projected date is December 2016. This process is
continuous. Nurse Informaticists, super users, information technologists,
Nurse Educators and vendors, will serve as continuous support systems for
all end users. An evaluation of the system post go live will be conducted. At
which time systems amending will commence.
Overall, this paper identified a workflow issue in the current system being
utilized at Queens hospital center. This writer proposed a new electronic health
system that would remedy the issues. Communication among the CPEP / ED nurses
and the inpatient nurses was identified as a workflow issue. The CPEP nurses had
difficultly giving nurse to nurse patient report to the inpatient nurses. The delay
often caused congestion in the ED. The inpatient nurses refuse or delay the report
process as a mean of lighting up there work load. The inpatient nurses complained
that the ED would call to give report towards the end of their shift. They also

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complained that CPEP nurses would try to admit patient to the unit without a MD to
MD report and without medical clearance.
The current system was analyzed and gaps were identified in the process. It was
evident that the need for a standardized system that would facilitate a SBAR report
was needed.

The new system used state of the art technology to improve

communication between the interdisciplinary team. An electronic report would be


entered into the new system which interfaces with a display board in the ED and the
inpatient units and serve as a visual aid. The new system would alert the nurse that
a SBAR report is completed and a patient is scheduled for admission to the unit.
These notification would also alert the receiving doctor. The many features of the
new system were discussed however, the new system is not meant to replace the
traditional verbal report. It is meant to improve and or facilitate the ED to inpatient
nurse report time and create a seamless process for patient transfers.

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References
Mastrian, K.G., McGonigle, Dee (2015). Nursing Informatics: And the Foundation of
Knowledge (3rd ed.) Burlington, MA: Jones & Bartlett Learning.
http://www.jointcommission.org/at_home_with_the_joint_commission/sbar_
%E2%80%93_a_powerful_tool_to_help_improve_communication/ Margherita Labson R.N.,
M.S., Executive Director Home Care Program, April 2015

http://www.nyc.hhc.org