| Principal Investigator: | Ann D. Shepard, MSN, RNC |
| Co-Principal Investigator/Collaborator: | Marita M. Schifalacqua |
| Organization: | Catholic Health Initiatives |
Abstract
Problem
Variation within clinical documentation practice for 15,000 staff nurses in our system of 71 hospitals in 19 states. Change is needed to ensure all patients within our health care system receive evidenced based clinical care and that the care is captured and retrievable.
Evidence
Evidence based content used was available to us from one of our clinical documentation software vendors. In addition to national professional practice standards, evidence based content from national supporting agencies (e.g.: Centers for Disease Control Infection and Immunization standards, American Heart Association vital sign standards, Institute for Healthcare Improvement and National Institute for Quality) was used.
Strategy
Clinical content teams called Temporary Action Groups — TAGs — composed of clinical experts, staff nurses and managers used change acceleration processes and facilitated meetings with rapid cycle decision making to validate and expand starting evidence based content.
Practice Change
Procedural model of creating evidence based standards of care and documentation moving from an isolated single hospital design to a national model of defining documentation standards.
Results
Outcomes measured dealt with a new representative model of developing national standards that are evidenced based. These standards are being incorporated into all new builds of the clinical information technology systems. Competed 150 Med/Surg, admission history, vital sign, obstetrics and emergency evidence based clinical documentation standards.
Recommendations
Formulating evidence based clinical documentation standards for remaining nursing and clinical ancillary focus areas. Lessons learned included that clinicians from disparate size and locations can come to consensus rapidly using evidence as the guide. We found that audio conferencing, with an internet on line meeting application was beneficial. The mixture of advanced practice, staff and management nurses resulted in knowledge balance on the calls.
Bibliography
- Stevens, K. R. (2004). ACE Star Model of EBP: Knowledge Transformation. Academic Center for Evidence-based Practice. The University of Texas Health Science Center at San Antonio. http://www.acestar.uthscsa.edu.
- Stevens, K. R., & Cassidy, V. R. (1999). Evidence-based teaching: Current Research in Nursing Education, 11.
- Stetler, C. B., & Marram, G. (1976). Nursing Outlook 24(9), 559–563. University of Minnesota Evidence Based Health Care Project. http:/evidence.ahc.umn.edu/ebn.htm.