Nursing Handoff Communication via Electronic Documentation

Implementation Context 

The problem, Setting and Context 

Patient handoffs are an indispensable constituent of contemporary medical care. Correct communication of information between one member of a healthcare to another is vital for it will lay down a foundation for improved patient safety and care. Nonetheless, medical errors have been known to account for increased health care costs and a decrease in healthcare facilities ability to offer optimum and quality health care. One of the leading causes of medical errors in a healthcare facility is a breakdown in communication. The occurrence of the failure occurs between healthcare practitioners and can happen at any level within a health care system. According to Kachali et al. (2007) and Singh et al. (2007), a breakdown in communication is one of the leading preventable errors in most studies conducted on medical errors. The facilitation of continuity of care, provision of a safe patent environment, and elimination of preventable errors is vital in the present-day collaborative care that is dependent on effective nurse-to-nurse communication.

The exchange of information between organizations, groups, and individuals is what encompasses communication. Nonetheless, for the communication process to be efficient, it should be timely, concise, clear and complete. Furthermore, an individual must have excellent communication skills that will safeguard the information being passed meets the expected standards. However, the communication process is marred by various challenges such as workload, conflict, fatigue, distraction, varying communication styles, defensiveness, hierarchies and lack of time. The patient handoff is a critical and predictive communication undertaking that occurs within any healthcare facility. The handoff process is made up of transferring of patient-related knowledge and information along with responsibility and authority form one nurse to another during transitions of care across the continuum. It should be made up of a prospect to enquire questions, elucidate, and ratify the information being conveyed . According to the Joint Commission (2010), it requires that “the process of handoff communication provides an opportunity for discussion between the receiver and giver of patient information.”

Impacted End-Users 

For one to ensure that a patient’s entire healthcare experience is at its highest levels, effective communication is vital. However, the healthcare practitioners who bear the most significant responsibility as the nurses. The nurses must have an ability to convey patient information regardless of the situation even though they are under intense stress. Despite the nurses having an ability to possess a vast amount of clinical expertise and medical knowledge, they tend to have huge setbacks when it comes to effective communication. From a patient’s intake until the discharge process, communication is a vital undertaking. As such, with the implementation of the clinical documentation system, the nurses will be the greatest impacted users . 

Additionally , the patients will also most likely become impacted for the nurses must first talk to the patients before feeding information into the system. The patients might require clarifications about the new system and how it will aid in improving their overall healthcare experience. In case the nurses do not provide effective and efficient information reading the CDS, some patients might end up being hesitant towards using it.

Traditional Communication vs. CDS 

The prognosis of a patient in most cases is done via email, phone or face-to-face meeting with a healthcare practitioner. The patients and nurses rely on the patient information provided thus should be accessible, accurate and timely. Nonetheless, communication at times might end up being unreliable making the patients vulnerable to medical errors that can bring about catastrophic impacts (Eberhardt, 2014). Provider to provider communication errors are just as prevalent as provider-to-patient, and they occur across all eels of the healthcare system . 

Nonetheless , regardless of the level that the breakdown occurs, the outcomes of the failures are servere for they can either increase the patient’s injuries or health complications and in a worst case scenario, it can lead to death. In relation to the nurses, it will impend their ability to provide quality, efficient and effective healthcare due to the emergence of medical errors resulting from the breakdown in communication resulting from data entry and handwritten errors and alter access of information (Eberhardt,2014) . 

Nonetheless , with the introduction of the clinical documentation system, it will automate the entire clinical charting procedure. All the patient information be available in real-time throughout the healthcare facility for it is relayed via an online platform. The CDS will computerize multidisciplinary recording at the point of care, make available a real-time access to patient data and judgement support, eradicate repetition of data entry and any probability of handwriting errors, inform the nurses at the point-of-care on any potential inaccuracies, permit the nurses to create a comprehensive audit trail, and offer an interface to bedside monitors and instruments. 

Stakeholders 

The implementation of any project must be accompanied by an input of various stakeholders to snore that it is a success. In this case, the CDS cannot be executed without the healthcare practitioners input. The team involved in the project execution will end up spending resources in trying to fix complications that might arise from the entire system. The enactment of the CDS will most likely impact e very department within the facility, and thus, the stakeholders, in this case, will include;

Financial Stakeholders 

In majority of cases, not every project has financial impacts, and therefore, it is vital for one to include the CFO, CEO and board members in the process. These individuals will play a vital role in explaining the financial impacts of the project once it is implemented . The project manager will thus have an ability to determine whether it is viable to enforce the undertaking. The project’s goals must align with organizational strategic objectives for the firm would not want to incur expenses that will not bring about an increase in revenues, customer outcomes and experience, and employee productivity.

Medical Leaders 

It is vital for one to include all the leader from various medical departments. The aim for this is to guarantee that each leader is aware of the implications and necessary changes that they must oversee to ensure the entire implementation is a success (Creswell et al., 2013). This will also make sure that the project leaders can get feedback that will aid in the development of the system implementation process such as training.

End-Users 

The end users, in this case, the nurses being part of the project can have tremendous impacts towards successful meeting the project goals and thus improving overall healthcare facility efficiency. The nurse will have direct interaction with the system, on a day-to-day basis. Hew project manager can elect a nurse champion who will play a vital role in the implementation of the entire system by advocating for it to other nurses.

Patients 

A project that has direct impacts on patients ‘overall outcomes can create later the affiliation between the patients and healthcare practitioners. It is therefore vital that the project managers get the patients’ perspectives. The managers can form patient-focus groups that will aid them in identifying any technology-related problems that will affect them when they decide to sue the CDS. The patients are any hospital’s final consumers, and thus their outcomes will determine the entire system’s formulation about improving the communication channels.

Vendors 

Getting vendor input before implementing the system is essential to ensure there is a smooth integration. The project manager should first determine the various vendor benefits that come with purchasing a particular system such as warranties, debugging options and any other software related issues. Additionally, it is also vital to determine the support capabilities of the vendors in case of system failure.

Competing Solutions 

Just like any other IT system, the CDS is marred by various setbacks such as being expensive to implement and its ability to become outdated thus requiring frequent updates. As a result, the SBAR (Situation, Background, Assessment, and Recommendation) is an alternative to the CDS. The tool was developed specifically for nuclear submarines by the USA military (Eberhardt, 2014). It was later adopted by the aviation industry and then incorporated into the healthcare industry. The sole aim for this was to facilitate any form of communication mishaps that resulted from the diverse communication styles employed by healthcare practitioners. SBAR is one of the most popular mnemonics ever implemented in the industry. SBAR has received positive recommendations from organizations such as the Royal College of Physicians based in London and as part of the Interventions to Reduce Acute Care Transfers in the USA that was aimed at reducing hospital readmissions . According to Ritcher et al. ( 2016) SBAR can play avital role in helping nurse to organize information into a coherent, and simply recalled pattern which accelerates the handoff process and decreases errors. More importantly SBAR once implemented will never become outdated and is not expensive.

Implementation Approach 

Key Change Champions 

According to Soo (2010), champions are crucial towards the overall success of any clinical project implementation that aims at boosting patient safety practices. Nonetheless, to ensure that such practices are implemented , the current methods must be changed to better ones. Nevertheless , a not e very individual within an organization is happy about the various changes that will take place. Change has been known to face a lot of resistance and if not well managed, the entire project is likely to fail thus the attainment of set objectives and goals becomes impossible. In this case, implementation of the DCS will require critical champions to make certain that is a success. One of these is the clinical champions who major role is to confirm that he/she supports the entire system implementation process by advocating about its importance to the other clinicians and aiding in down and upstream communication. According to Soo (2010), clinical champions will also help in building positive relationships with the end users through establishing a personal rapport with the nurses on the ground . 

Additionally , the clinical champions will educate the nurses on the importance of innovation by providing them with a more detailed presentation about the system and its usefulness. This is facilitated through presenting the nurses with educational materials such as posters, stickers, and pamphlets that will provide meaningful education. Another key group of champions is made up of the super users. Despite being less opinionated than the clinical champions , they have a broad awareness with the new system and thus can assist the other nurses in case they are facing difficulties. The super users will ensure that the other colleagues do not meet any challenges with the new system that might make them have negative attitudes towards the CDS. In the long-run, following assistance from the super-users, all the individuals will have an awareness about the CDS and use it with ease.

Risks and Mitigation Strategies 

The management of the system implementation process is a difficult undertaking. In case it is not one as per the recommended framework, it can cause headaches for the entire organization’s staff. It is, therefore, vital for one to identify the risks that might arise during the implementation processing come up with relevant mitigation strategies. Some of the risks that might implement the CDS includes;

Employee Resistance 

In most cases, end-users must be part of the entire system implementation process . Nonetheless , most project managers tend to label them as being a demanding group of people and can derail the schedule for completing the project. As a result, the end users will not be involved a lot of projects leading to growth and development of resistance (Haddara & Moen, 2013). The opposition is based on a couple of factors one of them is fear. In almost every human being’s agenda, fear must exist . People tend to dislike a change in the status quo despite one spending countless hours complaining about the frustrations and inefficiencies of the status quo . 

Additionally , people tend to think that a new system will bring out any weakness in their current working strategies. The result of this might lead to one getting fired or even demoted. However, to ensure that resistance does not affect the implementation process, it is vital to get a high number of end users involved throughout the system development stages. This will allow users to be aware of any problems that the old system has and ho the new system can eliminate them and increase their job productivity. In the long run, one will form a foundation of user acceptance after implementation making the entire process a success.

Data Conversion 

The communication process is made up of relaying patient information from one nurse to another within a similar or different department. Therefore, with the new system being computers, the conversion of data from the old patient records to a new system might become a real problem for the healthcare facility. The traditional patient information is recorded on paper, and some of the issues that might arise during the conversion stages includes missing data, data elements from the old system might have different meanings in the new one, the old system might have data that is questionable regarding accuracy and validity and poor quality. Nonetheless, to guarantee this does not happen, there is a need to analyze the current data much earlier before the system implementation process (Reeve, 2013). Additionally, the data should be mapped according to the new system’s data elements. This will certify that the data clean-up process is more efficient and effective thus allowing for valid, accurate and reliable data to be entered into the new system when it begins running.

Inadequate Training 

Training is a vital undertaking for any project after its implementation. In a majority of cases, the system users do not have an awareness of its full operational requirements and capabilities. Therefore, an underestimation of the need for training and lack of attention during the training sessions will have negative impacts not only on the system but the entire organization (World Summit on the Knowledge Society & Lytras, 2010). As a result, it vital for the project manager to set up a training schedule that focuses on all aspects of the system. More importantly, it is essential for the individuals who offer training to a have a vast comprehension of the system and ensure the trainees acquire all essential information on how to use the system . There is also a need to set up training timetables within the organizational official communication channels such as notice boards or website to guarantee that all the staff is aware of the training periods . After the training sessions, employees should take exams that will be used to determine which areas need further training and point out individuals who require additional training.

Data Sources 

Clinical data is a vital requirement for any healthcare facility this data is in mostly collected during the ongoing patient care or at times as part of clinical research trial (Proksha, 2011). In this case, the crucial data sources, in this case, will be electronic health records data, claims data, patient-generated data and pharmaceutical data. The electronic health data is gathered at a medical, clinic or practice’s point of care. The electronic health records data is one of the purest data sources and is not available for research purposes. This data will include the patient’s insurance, hospitalization, physiologic monitoring data, prescription drugs, diagnosis, and demographic information. The claims data is made up of the insurance claims between healthcare delivery system and the insured patients (Tailor, 2016). This data falls into four categories enrollment, pharmacy, outpatients and inpatient. Claims data sources can be obtained by a healthcare facility form commercial health firms or government. Patient-generated data is gathered, recorded or created form the family members, caregivers or patients with the aim of addressing a particular health concern (Tailor, 2016). This can include lifestyle choices, symptoms, biometric data, treatment history, and health history. Pharmaceutical data is used in determining the patient’s past medications help in patient diagnosis and treatment.

Implementation Plan 

Rollout Plan 

The healthcare facility has been using a traditional communication channel that has brought about reduced patient care and safety. Nonetheless, the organization would like to implement the CDS with the aim of boosting effective communication between the nurses. The implementation of the new system will require all the end users to corporate and ensure fully a success not only for them but also the patients. The human resources needed of the rollout plan will include the project manager, administrative manager, content experts , graphic designers, writer/editor, training databases and system access permissions. Additionally, the various hospital's service lines that will get an implementation of the system on a week interval from one to the other beginning with the surgical lines (cardiac surgery, orthopedic surgery, rectal and colon surgery). This will later be followed by the emergency medicine lines, intensive care, and birthing centers. The anatomical lines and patients record lines will be the final phases for the CDS implementation.

Education Plan 

Successful implementation of the system requires that all individuals have an awareness about the entire system’s operational functions. Therefore, there is a need to formulate a training plan that will ensure the end-users acquire the know-how as indicated below;

Training Dates	Units	Training Methods
October 11-31	Information required in CDS	Presentations and Lectures
November 1-21	Inputting Information into CDS	Lectures and CDS access
November 22-December 10	How to interact with each other using CDS and identification of errors	Lectures, Presentations, and CDS access
Examination dates	Testable areas	Examination Methods
November 2-6	Information on CDS	Questions and Answers
December 2-6	How to input information	Practicals
January 1-6	Interaction with CDS	Practicals and Q&A

Database Connectivity and Integration 

Most of the data is distributed across multiple healthcare applications thus accessing it all at once is a big challenge. As such, this data is not centralized which will make it hard for one to get the facts required at the particular time. The applications are running on-premise thus they do not talk to each other. This brings about the need for manually pulling data from the databases. This process is not only time consuming but can affect the validity and reliability of the information . 

Furthermore , many applications will not allow one in making ad-hoc reporting. In order to certify that there are data integration and connectivity for much easier access to the information, there is a need to seek the services of a cloud reporting and analytics from . These firms have aide range of integrators and database connectors that will make it possible for the organization to access all the data within ease/an example of such companies includes Microsoft Azure, Oracle E-Business Suite among others.

Environmental and Cultural factors 

The major environmental factor that might implement the organization’s ability to implement the system is power outages and natural elements . The system requires a 24/7 power supply for it is computerized. Without power, the nurses will not have an ability to engage in any form of communication. Additionally, natural calamities such as hurricanes, floods, and winter can affect the system’s operational capabilities . This is by destroying power lies, affecting internet connectivity and can even damage the hospital infrastructure. Globalization and technological advancement can also disrupt the implementation of the system. With each new day, there is a new technology that is developed , and this might make the implemented system to become outdated much quicker an indication the hospital will have to seek a better technology that is most likely expensive . 

Moreover , cultural factors can also negative impacts on successful implementation of the system. The patient’s perceptions regarding the use of technology at times impend the overall success of the system. Most individuals have confidence in that their personal information is not safe once it is input into computers connected to an online platform. As such, this will affect the nurses’ ability to effectively communicate with each other if some patients hold back some information. Organizational culture can also affect the system’s implementation. In case the employees believe the CDS will bring about job losses, they will resist its application thus derailing the entire system application. Technological know-how can also affect system implementation. Individuals who have less experience will require more training, and this will indicate that the system implementation will have to take longer.

Existing Processes 

The current workstation set-up is formulated in such a manner that the nurse can talk to each other using telephones or papers put in files. Nonetheless, with the introduction of the CDS, there will be an addition of computers, laptops, and tablets on the various nurse workstations. Most of the communication will occur via the CDS system in case it is related to a patent. The telephones will only be used for making clarifications on various matters . The tablets will be used in case a nurse is located far aw from his/her desk. As well, there will be an increased network set up throughout the hospital both wireless and Ethernet cable outlets. This will allow for effective CDS communication. More importantly, there will be a need to connect all the hospital systems to a new back-generators that will ensure there is still effective communication even during power outages. In the case of policies, no nurse will be allowed to input patient information on paper-records. All the data will have to be entered into the CDS system. Additionally, there will be o sharing of CSD system passwords for each nurse will have to use their log-in details when accessing the system . Sharing of the password will lead to harsh penalties.

Implementation Goals and Evaluation 

Goals 

There should be an increase in the nurses’ job productivity which is measured by the number of patient attendance. Effective communication will indicate that there are minimal errors hence little time is spent on clarifications and correcting of errors. Likewise, accessing patient information is much quicker thus allowing for faster diagnosis and treatment. There should also be increased patient care and safety. This is determined by the reduced number of readmissions resulting from medical errors as a result of ineffective communication. More importantly, the nurses’ employee satisfaction rates should be much higher due to a better communication platform determined by the job productivity rates.

Theoretical Framework 

The socio-technical theory will be used as the theoretical framework for this project. According to the theory , an information system is defined as an amalgamation of unified elements working together to disseminate, store, process, retrieve and collect information that will later be used in the planning, control, coordination and decision making by a firm (Carteli,2007). The main reason for selecting the use of an IS by a firm is to allow for an efficient and effective distribution of information within system thus giving it a competitive advantage over similar firms operating in its industry. The theory states that the IS made up of two vital components, the people and structures. (Cartelli, 2007) In the case of technological systems, they are formed of processes and technology and thus it is right to state that an IS made up of people, structures technology and processes (Cartelli, 2007). In this case, the CDS is an information system, and for it to fully function, it must have all the four components, and this makes the socio-technical theory the best theory to use in the project’s evaluation.

Feedback Methodology 

Feedback will be gathered through three different methodologies. The first is by way of team meetings. The nurses will have weekly meetings whereby they ill encouraged to provide feedback on the new system. The sessions will be open and interactive to ensure that any no individual fears are airing some negative feedback . 

Additionally , suggestion boxes will be placed in various locations within the hospital. The nurses will be asked to provide their output on the new system and the responses collected on a weekly basis. This is to nurse that any concerns about the system are solved within the shortest time possible. Nurse surveys will also be used in gathering feedback on a monthly basis, and every nurse will be part of the entire process.

Milestones 

Before rolling to the entire system in the organization, 80% of the nurses must have undergone thorough training on how to handle the system . The remaining 20% will be trained once the stem is fully implemented . Additionally, all the patients must be informed of the new changes at the healthcare facility through notice board and local media advertisements. This is to ensure that the patients are aware of the hospital activities thus building trust and credibility. Furthermore, 90% of the crucial data must be ready for entry into the new system before its implementation. It will ensure that there is minimal time used in entering data and elimination of unnecessary errors.

References

Cartelli, A. (2007). Socio-technical theory and knowledge construction: Towards new pedagogical paradigms? Issues in Informing Science & Information Technology , 4 .

Cresswell, K. M., Bates, D. W., & Sheikh, A. (2013). Ten key considerations for the successful implementation and adoption of large-scale health information technology. Journal of the American Medical Informatics Association , 20 (e1), e9-e13.

Eberhardt, S. (2014). Improve handoff communication with SBAR. Nursing2018 , 44 (11), 17-20.

Haddara, M., & Moen, H. (2017). User resistance in ERP implementations: A literature review. Procedia Computer Science , 121 , 859-865.

Kachalia, A., Gandhi, T. K., Puopolo, A. L., Yoon, C., Thomas, E. J., Griffey, R., ... & Studdert, D. M. (2007). Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Annals of emergency medicine , 49 (2), 196-205. a

Prokscha, S. (2011). Practical guide to clinical data management . CRC Press.

Reeve, A. (2013). Managing data in motion: Data integration best practice techniques and technologies . Waltham, MA: Morgan Kaufmann.

Richter, J. P., McAlearney, A. S., & Pennell, M. L. (2016). The influence of organizational factors on patient safety: Examining successful handoffs in health care. Health care management review , 41 (1), 32-41.

Singh, H., Thomas, E. J., Petersen, L. A., & Studdert, D. M. (2007). Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Archives of internal medicine , 167 (19), 2030-2036.

Soo, S. D. (2010). The role of champions in the implementation of patient safety practice change. Healthcare Quarterly , 12(Sp), 123-128.

Tailor, K. (2016). The patient revolution: How big data and analytics are transforming the health care experience . Hoboken, NJ: John Wiley & Sons, Inc. 

The Joint Commission . ( 2010). Comprehensive accreditation manual. CAMH for hospitals: the official handbook . Oakbrook Terrace (IL)

World Summit on the Knowledge Society, & Lytras, M. D. (2010). Knowledge management, information systems, e-learning, and sustainability research: Third World Summit on the Knowledge Society, WSKS 2010, Corfu, Greece, September 22-24, 2010: proceedings, part I . Berlin: Springer