Revised variance tracking system sparks better documentation, data
Goal includes replacing nursing care plans
Myocardial infarction (MI) patients admitted to the emergency department (ED) at Dominican Santa Cruz (CA) Hospital are transferred to the catheterization lab sooner thanks to variance data collected from the hospital's clinical paths.
Variance data also alerted staff to a problem with the hospital's cardiac surgery patients, says Elise Dempsey, MS, CCRN, outcomes manager at Dominican. "Some patients who had surgery late in the week were unable to complete cardiac rehabilitation because the rehab staff weren't there [on the weekend]. We rearranged the staff so the patients could remain on the path without that variance."
Those are just two examples of how the 380-bed hospital's variance data are used to improve quality. The hospital's variance-tracking program, which originally was implemented two years ago, was revised and reintroduced in April 1996 because nurses wanted to improve their methods of documentation.
"The path and problem identification record replace the nurse's care plan," explains Lynda Stratton, RN, outcomes manager at Dominican.
Now nurses use a documentation-by-exception system, and data collection efforts are standard hospitalwide. Unmet interventions or outcomes listed on the paths are documented on a separate form using a coded letter and number system. Variance data reports are distributed to process improvement teams and highlight areas for improvement.
To begin standardizing the data collection efforts, administration appointed a nursing chart revision committee. "We realized that we would encounter problems and knew that we needed to have nurse input in making any changes hospitalwide. It's important to have nurses make the decisions so they realize the changes are not just from administration and that they had representation on the team," says Dempsey.
The committee included nurse representatives from the hospital's five units:
* medical/surgical;
* oncology;
* neurology;
* telemetry;
* intensive care unit.
Changes initiated
As a result of a series of meetings, the chart revision committee recommended the following changes:
1. Create a standard pathway development system.
Dominican Santa Cruz has 35 clinical pathways in various stages of development or use, says Stratton. Pathways now are constructed by multidisciplinary teams that use the following system:
* development;
* trial;
* implementation;
* improvement.
Teams use a template for developing the path and incorporate interventions and outcomes specific to their patient group. The major care categories listed on the clinical pathway template and the designated code include:
* assessment -- A;
* physical activity -- P;
* treatment -- T;
* medications -- M;
* IV fluids/blood products -- I;
* nutrition -- N;
* comfort/pain -- C;
* education -- E;
* lab/X-ray/tests -- L;
* specialty consult -- S;
* future care -- F;
* outcomes -- O.
The template also includes delivery of care intervals -- such as days, hours, or phases. (To see how the care categories and delivery of care intervals are incorporated into a pathway, see the Community Acquired Pneumonia pathway, p. 115.)
2. Rename the variance tracking form.
"The in-house chart revision committee determined that the only way to get everyone to use the [forms] was to make it part of the documentation system. We changed the name of the variance tracking form from the Multidisciplinary Care Plan to the Multidisciplinary Problem Identification and Documentation Record. Incorporating the word "documentation" enforces the importance of using the form for documentation purposes. (See copy, p. 116.)
Variances are documented by any member of the multidisciplinary care team providing care to the patient, including ancillary services and unlicensed assistive personnel. The five broad categories of variances are:
* patient/family;
* care provider;
* supply/equipment/staff;
* procedure/policy;
* community.
"During the revision process, the issue was raised that we didn't have enough [variance] codes. But we looked at what other facilities were doing that had 50 to 100 codes, and even they were having problems, so we decided to keep our five broad, general categories," explains Dempsey. That was one of the elements of the old system that was kept in the revised system.
3. Keep the path and other documentation forms in the medical record.
Pathways now are located in the patient's medical chart under a tab divider labeled "clinical pathway." Although paths have been a part of the patient's medical record since they were introduced at the hospital, each department placed them in different areas, says Stratton.
"Some were kept in the chart, some were on the beds, and some were on the medication chart. We decided to put it in the chart with the divider to reinforce that it is a charting documentation tool," she explains.
4. Provide frequent feedback.
Monthly pathway management reports are distributed to process improvement teams. Each team outlines a course of action for variances selected by team members, says Dempsey. Patient variances are addressed concurrently during the hospital stay, but variance data are entered into the hospital database following discharge. The variance database, which was developed by a physician and colleague for use internally at the hospital, is maintained regularly by a dedicated staff member. (To see how process improvement teams use the management reports, see the related story, p. 117.)
Outcomes managers at Dominican Santa Cruz spent three months educating staff about the revised variance tracking program. "We set the stage for the staff to understand why we use paths, how they fit into the bigger picture, and how hospitals are reporting this type of data to payers and outside agencies," explains Dempsey. *
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