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 – – – – – 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 – Staff movement Frequent indents from stores Inventory Stock of redundant forms Inventory of multiple forms Challenge of ROL – reorder levels Wear & tear People Effective time per patient Compiling & sequencing the file to be sent to MRD at time of discharge Paperwork Burden Waiting Delay in indent Stock outs Patient waiting for staff to attend, when nurse collecting & filling the forms Over production & Overprocessing Repetition of information in different forms. Defects 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: 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