Knowledge-Based Charting Brings Instant Relief to Fairview Health Services Southdale Hospital
Mention the words "Joint Commission" and heart rates begin to rise. This past August, The Joint Commission paid a surprise visit to Fairview Southdale Hospital of Edina, MN, which proceeded to pass the audit with no "Recommendations for Improvement" in any standard. Four weeks before the audit, Fairview Southdale went live with Eclipsys' Knowledge-Based Charting™ as part of a larger effort to introduce fundamental culture, practice and workflow changes across the 419-bed facility. Fairview Southdale is the pilot facility in the Fairview Health Services system for this clinical-transformation effort.
Eclipsys recognized Fairview's significant success at EUN™ '06 (the Eclipsys User Network™ Annual Conference last fall) with the Very Impressive Performer (VIP) Award for Transformation. As the first recipient of this new award, Fairview illustrates in dramatic terms the significant reality of how a pre-configured, well-designed clinical documentation system enhances a clinical-transformation effort.
Fairview Health Services has been a long-term Eclipsys customer, deploying Sunrise Clinical Manager in four of its metropolitan hospitals. This most recent implementation of Knowledge-Based Charting resulted in dramatic clinical outcomes (see sidebar on Fairview outcomes).
Fairview's experience with Knowledge-Based Charting is, in one important way, typical. Virtually immediately upon installation, Fairview realized the benefits of a pre-configured, evidence-based clinical documentation system. Judy Pechacek, RN, MSN, vice president of patient care and chief nursing officer of Fairview Southdale Hospital, is the senior executive responsible for this ambitious effort to fundamentally change practice and patient care in her organization.
Recently, Judy and Bonnie Wesorick, RN, MSN, Eclipsys' executive vice president of practice and founder of its CPM Resource Center™, met to talk about some of the lessons they are learning from Fairview's experiences.
Bonnie | Can you talk about the challenge of getting people excited about major culture and practice change?
Judy | I think the work the Eclipsys CPM Resource Center team did with our interdisciplinary team helped build that passion and re-engage people to the core of their caring. Everyone understood at an intellectual level that things were going to change. Now - after the go-live - we're engaged in a year-long process of true adoption. My expectation is that it will probably take a year to truly get there. It's during this process where the real rubber meets the road. We're trying to use every feature of the software to its fullest because you can't do that when you first turn it on. You have to move around in it and the team has talk about how it changes practice, how it changes people's roles and that kind of stuff. The other thing is that practice and trust and relationships aren't something that you can change by flipping a switch. They are at the heart and soul of caring, and a clinical transformation involves each team member differently.
Many of our people are now living with the reality that life is different and that comfortable old practices are no longer there. They're discovering they need to give up some things to get some new benefits, and that's really hard right now.
Bonnie | That's the wisdom of a real clinical transformation, Judy, and why you're successful. There are people who think that once technology is live, the project is complete. You've had the clarity and courage to understand that implementing Knowledge-Based Charting is really about practice transformation; the technology is merely the tool you've chosen.
I've observed that people get confused about a technological go-live and clinical transformation. Some people think they're the same thing...and they're not. Why do you think you have such clarity about that?
Judy | I guess it's due to personal experience from doing it wrong. I love that because experience is the best teacher. I'm an experiential learner and I know what it's like to put something in and be surprised when no one uses it. Lifting equipment is my prime example. We've made substantial investments in lifting equipment here at Fairview Southdale. You'd think that anyone could see the patient and caregiver safety benefits of lifting equipment. You would also think that people would use it wherever possible. That turns out not to be the case. Lifting equipment is about cultural change. It involves letting go of old habits - yanking patients up in bed by their armpits - and taking the time to do it right, to do it safely. I think this illustrates the challenge of any new change.
Bonnie | When the Eclipsys team came back from Fairview, they were exhilarated. So I asked, "What is all this joy about?" They replied, "You just don't have enough experiences where the client - referring to your team at Fairview - really focuses on the preparation work instead of just charging headlong to reach go-live. We were thrilled to see a client preparing for practice change, not just the technological change."
We saw an unusual level of engagement and interest in practice change at Fairview. Did you also see that kind of engagement from your leadership?
Judy | Yes, every senior leader knew exactly what was happening on the team. They have to be because this effort affected every discipline, every physician, and it dramatically changes the lives of patients. Our patients are experiencing a difference in care. Our president was and still is engaged because he believes that this is transformative as well. He showed his support by attending issues meetings; in fact, he actually showed up at our routine planning meetings. And then in rounds just this week he sent me an email that said, "Jane on station X is having some concerns about her knowledge of Knowledge-Based Charting. Can we get her a little extra help?" It's admirable and I think that's the kind of support you need.
Bonnie | We're always asked by other clients about engaging senior leadership. Did you have a healthy relationship before this effort began?
Judy | We're a new leadership group and are still forming as a team. I think there was a shared understanding about what it meant if we didn't succeed. The Joint Commission audit also helped to focus our attention and resources. We had 19 issues with The Joint Commission and were facing the prospect of nonaccreditation or provisional status if they weren't fixed. That helped concentrate multiple minds!
Bonnie | So it was very clear that there was a shared purpose, a common ground. Did you have any surprises during this process?
Judy | I wouldn't say there were surprises. Instead, I would say we had many moments of joy. There were times that brought you to a place of joy because you would see a nurse, a pharmacist and a social worker with their heads together trying to solve a patient's problem. Many of these moments occurred immediately after go-live, when there was strong pressure to resolve issues yesterday! Since Knowledge-Based Charting delivered the goods right away, we saw immediate results. In the midst of all that pressure, it was extraordinary to see such deep collaboration and respect for one another.
I also have to say that the impact of the clinical practice guidelines - CPGs - was really dramatic in some cases. I was doing Knowledge-Based Charting rounds in the ICU unit and a veteran nurse came up to me and said, "Judy, this saved my life. I was taking care of a patient who had been diagnosed with DIC after her C-section. I hadn't cared for an obstetrical patient since nursing school. I clicked on that practice guideline and was reminded of how to perform the interventions and to watch for certain things. It made me feel better that it was there and that I was doing everything I needed to do, even though I was caring for a patient in an unfamiliar setting. I could kind of exhale."
Bonnie | You know when you were talking about those joyful moments? That's how I feel when I hear your story. Many years ago when we began the journey of Knowledge-Based Charting, we wanted to provide that sense of security for nurses and the interdisciplinary team providing hands-on care. All of us had been in the shoes of that nurse you described. Every nurse has experienced the fear that maybe they wouldn't have enough knowledge to take care of a patient. The beauty of the practice guidelines is that they quickly remind nurses how much they do know and provide that extra information they may not recall in the moment. And that is so powerful to be able to ease the burden. It helps you feel like you're not alone.
I really appreciate that story because I think it is a vivid illustration of the realities many clinicians have experienced. It also shows that Knowledge-Based Charting is working to serve clinicians in their quest to give excellent care.
You mentioned that you started to see a more collaborative, interdisciplinary care process fairly quickly?
Judy | We saw it right away. People were surprised when this really solidified true interdisciplinary practice for us, so it was very exciting. That's why I think it's important that all disciplines share responsibility for the go-live and ongoing care transformation. When everybody feels the pain at once, everybody feels the joy at once. I also think there is no way to push people to get at deep practice issues if you allow some to straggle behind and not use the system. I believe it results in a chaotic, prolonged and unnecessary process. It's far better to feel the pain together for a couple of weeks so you end up "forcing" those moments of joy.
Bonnie | Have you noticed anything in the interdisciplinary team's approach to teaching the patients to care for themselves?
Judy | I've noticed that we all share that. I also think there has been a recognition of each other's contributions. Now, we have between one and four disciplines charting on the education flowsheets. Before we implemented Knowledge-Based Charting, it was only the nurse.
Bonnie | Have you received any patient feedback?
Judy | During this year of adoption, we want to engage our patients very directly in their plan of care. Most of our staff want to feel competent with the software and are anxious to chart in a way that isn't obtrusive to the relationship they're trying to have with their patient. So we needed a few months to get through that; now, our clinicians are rounding and charting at the same time. We have folks who are doing the entry-point assessments and using laptops or computers on wheels right in the room with the patient.
For some of our staff, it's been a journey to get comfortable interacting with the system in front of patients. We're working through a number of issues in this area. The technology itself is not so much the problem as folks not wanting their back to be to the patient while doing an assessment. We're experimenting with different wall mounts and keyboard swivels and so forth. Sometimes, it's hard to recognize that there are issues until you're in the middle of them.
But we have to set an expectation that usage of the system isn't optional. We hope that all of our staff will experience the pain and the joys we just talked about as they interact with patients to devise that plan of care. This will be a major accomplishment and we think the entire care team will celebrate once it is hardwired into our way of caring. That will be a very beautiful thing.
Bonnie | Can you talk a little bit about the staff transition into evidence-based practice?
Judy | We've been on that journey for a number of years. Many of our staff were reluctant to rely on this kind of material. The reputation was that while it may be good for cardiovascular, for example, it may not be as strong in other clinical areas. Knowledge-Based Charting brought some dependability to the whole idea of evidence-based practice. Staff now know they can rely on it, it is easy to access, and that it is just drop-dead the best thing in the whole-wide world.
Bonnie | Would you have any advice for a hospital contemplating clinical transformation?
Judy | I think it's not for the faint of heart. Getting ready for the go-live takes time and organizational focus. Three months beforehand, my constant mantra was "No" to other projects. Everything we did was about Knowledge-Based Charting. We had a true laser-beam organizational focus. Once the go-live arrived, we had to prop people up and say, "You know that during this week of go-live, nothing happens in this organization but Knowledge-Based Charting."
Everyone needs to recognize that Knowledge-Based Charting has a tremendous effect on the way care is delivered. This means that there is no alternative but for everyone to have that laser focus. Like I've said, it's not a finance issue and it's not a time issue - it's a priority issue.
Bonnie | Thank you, Judy, for participating in this interview and sharing your wisdom with us. Your leadership is courageous and inspiring!
Judy | It was my pleasure, Bonnie, and thank you.
Outcomes
Fairview Knowledge-Based Charting Outcomes
Achieves 100% Joint Commission compliance and improves quality of care - four weeks after activation
100% compliance with Joint Commission performance standards related to:
Pain assessment
Fall prevention
Plan of care present
Individualized plan of care
Patient education
Interdisciplinary documentation of care
75% increase in number of patients with an individualized plan of care, achieving 100% compliance
17% increase in number of patients with documented education
Other Publications
This article appeared in the Outcomes in Healthcare Excellence-Spring 2007 newsletter.
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