CARE-EPIC - Strengthening Patient care through Innovation in Nursing Care Records
"Dock to Stock Cycle Time Reduction”
Key words:
Lean Principles, A3 Thinking, CARE-EPIC-Comprehensive Assessment Record for Evaluation
& Efficient Patient Integrated Care, VSM – Value Stream Mapping, WOMBAT - Work
Observation Method By Activity Timing,
Abstract:
Properly documenting care in a patient's medical records is essential & as per professional
standards; for evidence as well. Inaccurate & incomplete data spread across various documents
may lead to overlook significant information attributing to continuity of care & patient safety.
Documentation pattern of nurse deserves revisit periodically; otherwise it may lead to inordinate
addition to forms with most of it adding redundancy, repetition, making it ponderous for the staff.
Nursing documentation being an essential part of patient care use of "Lean" principles can
create real value by improving
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–
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Productivity
Quality of care
Effective time per patient per day
Operational efficiency
Cost optimization
Considering Nursing documentation an essential part of patient care, re-thinking on the
optimization of care records through implementation of "Lean" principles” in hospitals lead the
organization to create real value by reducing waste and improving productivity, costs, quality,
and the timely delivery of patient care services.
Introduction:
Nurses routinely spend approx 40% or more of their time in documentation while imparting
patient care & this conflict with personal attention. Most of all it takes away from their ability to
administer direct patient care, a significant issue for nurses. Survey conducted on nurses on
documentation revealed that paperwork was multifarious & perplex in addition to which
WOMBAT revealed that various nursing activities add no value to patient experience. Also,
Basis Current documentation there was a lack of trigger for superlative nursing care i.e. non
conformity to evidence based standards of care.
Considering this the team reworked on nursing forms used in non Critical care area, applying
Lean approach of A3 thinking to
1. Increase both patient and staff satisfaction
2. Improve Quality of patient care & patient safety by improving compliance to
documentation
3. Optimum utilization of nurses by reducing time spent in paperwork
4. Enhancing patient experience by improving effective bedside time per patient.
5. Eliminate waste with a focus on value to the patient
6. Standardize and simplify processes
7. Driving operational efficiency by eliminating waste/redundancies in documents
8. Aligning the goal of the unit with the strategic initiatives of the company.
9. Create process awareness across service lines and roles to stimulate continuous
improvement and innovation at the point of care.
Other specialized performance improvement tools were also used to support decision making
and enable transformational change
Problem Statement:
As mentioned almost 40% of time of nurses goes into documentation & 30% of related nursing
activities were dedicated to tasks which added no value to patient experience & resulted in
following process gaps or we may call it wastes.
Transport –
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Staff movement
Frequent indents from stores
Inventory
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
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Stock of redundant forms
Inventory of multiple forms
Challenge of ROL – reorder levels
Wear & tear
People
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Effective time per patient
Compiling & sequencing the file to be sent to MRD at time of discharge
Paperwork Burden
Waiting
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Delay in indent
Stock outs
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Patient waiting for staff to attend, when nurse collecting & filling the forms
Over production & Overprocessing
 Repetition of information in different forms.
Defects
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Missing of forms
Error of commission
Error of omission
Poor compliance
Diagnosis of Problem
Current nursing forms commonly being used for each IPD patient were thoroughly analyzed to
identify sources of waste and eliminate or reduce them. The team began to follow the lean
thinking process and gathered data to document the current state through following tools.
1.
2.
3.
4.
Staff Interview
Survey questionnaire
Document compliance audit
Fish bone /Ishikawa
Problem analysis
Once the wastes were identified, team identified the gaps and opportunities of
improvement in the process with the help following methodology
1.
2.
3.
Value Stream mapping
Time observations
Hands-off & Sphagetti
Solution Approach
With detailed analysis of each nursing form, identifying the wastes during & in documentation,
the Non Value Added steps were reduced by eliminating or reducing the duplications or
redundancies. This made the forms more Evidence based and simplified Comprehensive record
of all nursing forms named as CARE-EPIC i.e. Comprehensive Assessment Record for
Evaluation & Efficient Patient Integrated Care.
The CARE-EPIC was formed keeping into consideration of Standard Operating Procedures,
Accreditation Standards, MOS protocols and National or International guidelines. This record
has been designed for 5 days keeping the average ALOS of a patient.
Innovation was ONE SINGLE PATIENT RECORD for 5 days keeping the following into
consideration:
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


Average Length of Stay (ALOS)
Accreditation Standards
Hospital policies and Standard Operating Procedures
National and International guidelines
1. Lean Goggles were used by the team to reduce & remove the redundancies thus
leading to increased time in patient care.
2. Solution approach of EASE VS COST was used to arrive to the best solution for the
success of the project.
3. After implementation of the CARE-EPIC a Process control board was formed to
support the nursing staff on grounds and take feedbacks of staff.
4. Based on feedback provided by staff the team did PDCAs (Plan Do Check Act) and further
revised the CARE-EPIC making it simpler, useful, informative and user friendly.
IMPACT
With the implementation of CARE-EPIC record of nursing documents, WOMBAT (post project)
revealed some major achievements:
Evidence Based practice: By adding NEWS the care records have become more scientific for
standardized assessment of patient for clinical condition. It helps staff to raise early warning for
prevention of any adverse event.
Time: Nurses who used to spend more than 40% of time in documentation now has
significantly reduced by 25%. CARE-EPIC is a simplified document available at one place &
prevented the non value added movement of staff & missing of form.
Patient care: Lengthy & tedious documentation process of nurses prevented them to spend
more of their value time for direct patient care but with implementation of this care record, time
spent in direct patient care has increased by 53% .
Element Vs Compliance: Earlier there were nearly 622 odd parameters in all forms put
together, which had to be filled to complete the documentation resulting into non compliance
towards documentation. We reduced the number of elements by 55% which a nurse has to fill
for patient care & continuity of care, which resulted in almost 100% compliance to
documentation in records.
Operational Efficiency by reducing the wastes - There is huge direct & indirect cost which
was involved including:
a.
b.
c.
d.
Effective time loss per patient
Patient experience
Staff efficiency & productivity
Cost
With implementation of this care record we were able to control and minimize the costs.
Patient Satisfaction & Employee Satisfaction:
a) Patient Satisfaction Survey shows the rise in satisfaction due to prompt response of
staff.
b) Positive feedbacks of clinicians & Patient have resulted in high morale & lead to
Increased ownership for delivering the patient care.
c) Feedback of staff on use of CARE-EPIC was overwhelming & satisfactory.
d) Capacity Building: More than 400 staff have been impacted directly & 200 staff
indirectly, thus reducing time in documentation up to 25% has increase the staff
efficiency by saving thousands of man-hours per year company wide..
Lessons learnt
Strategic thinking, proper planning, communication, team commitment & desire to continuously
improve can bring in major /substantial difference in building a learned organization. There were
various challenges in implementation but were addressed appropriately through
1.
2.
3.
4.
5.
6.
7.
8.
Optimum utilization of resources
Adequate allocation of resources
Team work
Staff motivation
Patient feedbacks
Close monitoring of process
Continuous improvement through periodic meetings
RIE(Rapid Improvement event),formal trainings, sensitization on use of CARE-EPIC
through simulation project added to success
Conclusion
A project is successful only if it is scalable & sustainable. This project has some measurable
outcomes but the positivity, energy & convivial response of staff which was evident during the
project phase & feedbacks post implementation was immeasurable & was evident in the
success of project. The project is a live example of organization Values of Patient care,
Innovation, Teamwork, Ownership, which can bring improvement in any process & drive
efficiency.
But as rightly said, Quality is a journey & not a destination. Our learning is to improve patient
safety & we shall continue to conceptualize and construct quality & safety nets to mitigate
uncertainties.
Acknowledgements
We shall like to thank Mr. Prateem Tamboli, Facility Director of our hospital for his leadership
and continuous support to this project. We shall also like to thank Dr. Shrikant Swami, Medical
Suptd. & Ms. Jiji Mol, Chief of Nursing, her team of Nursing and all others who directly &
indirectly supported this project.
Reference:
Aiken L, Clarke S, Sloane D, Sochalski J, Silber J: Hospital nurse staffing and patient
mortality, nurse burnout and job dissatisfaction.
Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K: Nurse-staffing levels and
quality of care in hospitals
Author: Nihar Bhatia, Head Quality Assurance & Fortis Operating System
Author: Prateem Tamboli, Facility Director