The Miriam Hospital: Optimizing patient care, clinical
practice, technology and informatics
The Miriam Hospital (TMH) is a private 247-bed, not-for-profit, acute care general
hospital founded by Rhode Island's Jewish community in 1926. The Miriam Hospital
provides a broad range of primary, secondary and tertiary medical and surgical services
to adolescents and adults in 33 medical and surgical specialties and sub-specialties.
In 1998, TMH became the first hospital in the State of RI to achieve the Magnet
Recognition Status. At this time, it was only the 9th Magnet Hospital in the country to
boast the designation. Creating an environment to support and retain the professional
nurse requires an immense commitment. To sustain Magnet culture, nursing leadership
continually evaluates satisfaction and retention of clinically competent nurses. The
Miriam Hospital is the only hospital in New England to receive the prestigious Magnet
designation for the third time.
As Magnet organization, we have sought to integrate Nursing Informatics into our
professional practice model. Briefly here are some of the recent ways technologies, or the
desire to integrate technology into practice, has enabled the forces of magnetism directly
or indirectly:
1. Quality of Nursing Leadership
TMH has a Director of Clinical Informatics who reports
directly to the CNO/ VP of Patient Care Services and is a
member of the Nursing Executive Council. This Director
has a broad background in clinical informatics and is
well integrated professionally into the Nursing
Informatics community. The organization also seeks to
develop both it’s leaders and staff through continuing
education and has started to offer CEU accredited
Clinical Informatics programs to it’s staff.
2. Management Style
Through our professional practice model, we strive to
inspire one another to higher standards of care. We have
introduced the Clinical Informatics Council into our
professional practice model. This is one of our primary
councils for setting priorities and providing feedback on
the implemented suite of clinical applications.
3. Organizational Structure
We strive for alignment at the corporate, inter-affiliate
and affiliate level through our organizational structure.
Currently nurses sit on the following key management
councils:
- (Executive) IS Strategy and Steering Council (IS SSC):
- (Informatics Leadership across affiliates) LINC:
- (Senior Affiliate Leadership) TMH Systems steering
committee
ANCC: Pre-Conference T.I.G.E.R. Session
1
- (Staff Nurse) Clinical Informatics Committee
4. Personnel Policies and
Programs
We have well defined job descriptions for both our
Director of Clinical Informatics and Nursing Informatics
Staff Specialist.
5. Community and the healthcare
organization
Last year we were awarded the 2007 Barnett Fain
Quality Award for bringing our PVP (Pneumoccocal
Vaccine) rates from 43% to 91.7%. This was through a
team effort lead by our Director if Epidemiology. Yet
the Nursing Informaticist played a vital role supporting
education related to order entry and immunization
tracking using our core clinical information system. We
believe this allowed us to meet our quality goal and
provided a valuable service to the community.
6. Image of Nursing
One of the ways we are using technology to support this
force of magnetism is thru the development of our recent
Department of Nursing Intra-net. Our intra-net design
that supports both our professional council structure and
nursing departments.
This site supports department based and council
communication through council action logs, council
minutes, and threaded discussions. There are also
department specific hyper links and educational
resources available in multiple formats . This site has
been developed to support the professional practice
model, communication and reflect the diversity of
clinical nursing practice.
Also the Clinical Informatics Council has identified a
need for a patient safety brochure to help educate our
patients about BCMA (bar coded medication
administration) and their efforts to enhance medication
safety at the point of care.
7. Professional Development
Through staff participation, we are professionally active
at the regional level (NENIC: New England Nursing
Informatics Consortium), national level (HIMSS:
Nursing Informatics Task Force) and with our academic
partners (i.e. Rhode island College, University of Rhode
Island, Salve Regina). We have also been able to provide
nursing informatics educational offerings and in-services
during clinical placements.
We have also started to encourage staff to participate in
Siemens, our core information systems vendor, Nursing
Thought Leadership seminars.
8. Professional models of care
On June 13 our Director of Clinical Informatics
partnered with a Rhode Island College Assistant
ANCC: Pre-Conference T.I.G.E.R. Session
2
Professor to present Nursing Education, Practice and
Informatics: Partnering for the Future at RI’s Health
Care Futures Grant Educational Summit. The focus of
this presentation was an overview of a pilot to introduce
students, during their clinical placement, to the affiliates
information systems and Nursing Informatics.
Also Clinical Informatics: Nurses developing an
informatics culture and competencies was accepted,
as a podium presentation, at this years ANCC’s
Magnet Conference. The focus of this presentation
will be a review of how TMH is integrating nursing
informatics competencies, based on the work of
Nancy Staggers et al., into the TMH culture.
9. Consultation and Resources
The Department of Clinical Informatics has been
involved in many projects, workflow analysis and efforts
to prepare the organization for future systems. They
frequently act as a resource on many application and
integration issues. In addition, the department consults
and acts as a resource to groups both in the community
and affiliate:
o
To NENIC (New England Nursing Informatics
Consortium) as Director of Program Planning
integrating the needs of the service based
organization into program planning;
o
To the RI Affiliate of MONE (Massachusetts
Organization of Nurse Executives) in the overview
of the 2007 Massachusetts Board of Higher
Education and the Massachusetts Organization of
Nurse Executives (MONE), Creativity and
Connections: Building the Framework for the
Future of Nursing Education and Practice.
Specifically because one of the 11 competencies is
informatics and looking at ways we can prepare the
“Nurse of the future” from both the academic and
practice perspective.
o
To the TMH Risk Management department on most
root cause analysis related to multiple applications
and specifically CPOE (Computerized Provider
Order Entry) and BCMA (Bar Code Medication
Administration).
o
To the Information Systems department designing,
configuring and managing affiliate order sets and
bringing the practice perspective intro the
implementation lifecycle.
o
To care providers on a myriad of point of care
ANCC: Pre-Conference T.I.G.E.R. Session
3
application issues.
o
Finally to nursing, staff and other ancillary
departments as a bridge and translator to improve
computer skills and information literacy.
10. Autonomy
Many of the solutions are starting to introduce more
nurse driven protocols and order sets. For instance,
bringing our GENESIS protocols, our geriatric care
standards, on-line.
11. Nurses as teachers
The TMH Dept. of Clinical Informatics is involved in
reaching out to various academe centers (i.e. Rhode
Island College lecturer, RIC student mentor,).
This year the Clinical Informatics Committee provided
an overview of the systems, used throughout the
organization and from a nursing perspective, with a goal
of bringing this to the entire organization later this year.
Partnering with our Center for Professional Practice
Department (CPPD) to offer blended learning during our
Medical Surgical Competency fair. A needs assessment
was performed, learning deficits identified and a training
program developed. In addition, the following tutorial
‘movies’ were developed and made available on the web
site:
o Viewing available blood products on-line;
o Viewing the pharmacy profile;
o Adding patient allergies;
o Viewing the pharmacy profile on-line;
o Revising heparin orders.
Finally in 2007, we provided on going education and
training for TMH staff specifically the following:
o POM (CPOE) Training: 175 RN’s
o MAK (BCMA) Training: 360 RN’s
o POM for ED, VIR and Endo
12. Interdisciplinary Relationships
We have both studied “The impact of healthcare
technology on the role of Nurses and Interdisciplinary
Communication” in 2005.
Dykes, P. DNSc, RN; Cashen, M. PhD, RN;
Foster, M. RN, MSN, FHIMSS, CPHIMS;
Gallagher, J. RN; Kennedy, M. RN, MS;
MacCallum, R. RN; Murphy, J. RN, BSN,
FHIMSS; Schleyer, R. MSN, RN, BC, CPHIMS;
Whetstone, S. RN, BC Surveying Acute Care
Providers in the US to Explore the Impact of
Health Information Technology on the Role of
Nurses and Interdisciplinary Communication
ANCC: Pre-Conference T.I.G.E.R. Session
4
in Acute Care Settings. CIN: Computers,
Informatics, Nursing. 24(6):353-354,
November/December 2006.
Today we are reaching out to our physician colleagues to
optimize clinical communications by the way orders are
entered into our CPOE system. Specifically, our Clinical
Informatics Committee is developing a “Dear Care
Provider” letter outlining the “TMH Most Common
CPOE Order Entry Tips” to be distributed to our
order entry providers.
13. Quality improvement
Since 2004, we have implemented the following
solutions to improve the quality of care and patient
safety:
o
Clinical Documentation in many of our
procedural areas – Medhost in the ED, iPath
intra-operatively and MACLab in the cardiac
catheterization lab.
o
POM (CPOE) implemented throughout the
inpatient areas with 94% of our physicians using
the system
o
MAK (BCMA) implemented throughout the
inpatient areas
We implemented Vocera, an instant communication
device, into our ED and Main OR to improve the quality
of communication.. Highlights from a post
implementation survey indicate that respondents agreed
that the Vocera system enabled:
 A more efficient workflow (64%)
 More individual efficiencies (54%);
 Improved patient care coordination between staff
(64%);
 Improved teamwork among nursing personnel
(61%);
 Improved nursing staff ability to support each
other (66%);
 Reduced time spend walking the unit to find
people and making unnecessary trips (75%);
 Simplification of daily communication with
other staff (59%).
We are also developing Nurse driven order sets and
protocols from recommendations form our Evidenced
based best practices committee. We have specifically
focused on discontinuing foley orders; oral care protocol;
wound care order sets; geriatric consults and telemetry
orders.
14. Quality of care
Since we have introduced many technologies, we have
ANCC: Pre-Conference T.I.G.E.R. Session
5
had the opportunity to study and evaluate many of these
solution, specifically the following:
o The unintended consequences of BCMA around
patient identification, med error reporting and
data management;
o Medication reconciliation successes and failures;
o Managing contrast media as a medication
These are some of the ways technology has enabled the forces of magnetism. Yet we may
want to think that the forces of magnetism are actually helping us shape technology.
ANCC: Pre-Conference T.I.G.E.R. Session
6