Outcomes charting cuts LOS, boosts productivity
New forms also improve info, eliminate overtime
St. Peter's Home care in Albany, NY, faced the same challenge other agencies face: As more standards and regulations were implemented, documentation was amended. But the alterations were often haphazard, and the resulting forms were difficult to read and caused as many problems as they solved.
The agency, with 40 nurses and an average census of 400 patients, had a mass of forms, says Carol Ann Thomas, RN, quality improvement/ education coordinator. "There were little codes at the top of the forms that you put into boxes. There were a lot of pages. There were fold-out sheets."
But if you didn't use the forms every day - for instance, if you were the quality improvement/ education coordinator charged with chart audits and weren't used to filling out the difficult-to-read charts - the system was time-consuming and cumbersome to use. "You couldn't look at a chart and see where the person was in treatment," she explains.
Added to the volume of material were complaints from the nurses that they were spending too much time on paperwork.
The solution was to completely revamp the agency's documentation. Little did Thomas know how stunning the results would be: improved efficiency among nurses resulted in reaching the targeted productivity of 5.5 patient visits a day, a virtual elimination of overtime spent doing paperwork, and even a six-day decrease in average length of stay for patients.
Looking for the right model
Thomas says the first step was to see what forms were being used in the community. Some agencies shared bits and pieces of information, while others were less willing. Thomas says nurses who knew people in other organizations or used to work for them became a valuable repository of information on documents used by some area agencies.
Thomas also capitalized on her work as part of the utilization review committee at an area agency. "They let me take their visit record," she says, noting that they were reluctant because it was a copyrighted document. "But I said if it was copyrighted, what were they worried about?"
Two nurses were assigned to do literature and Internet searches, but Thomas says there was little published information. The nurses also looked at Joint Commission standards and local regulations. "We wanted to look at what was required," says Thomas.
The two nurses developed a sample form and took it to a committee made up of three nurses, a nursing supervisor, a physical therapist, an occupational therapist, and a registered dietitian. The committee members commented on the ideas and suggested changes. The nurses then sat down at the computer and created the pilot documentation in WordPerfect.
The changes were dramatic. For instance, the 400 listed treatment codes St. Peter's used were extremely specific, says Thomas. "They were so exact before that we lost track of them or would forget some." For instance, there was a code notation for weight checks at every visit. If that was forgotten even once, the Department of Health could - and did - cite St. Peter's for the lapse. The new treatment code list is only 100 items long.
Another big change came in the visit report. Initially, it was four pages long. "It added too much paper to files," she recalls. "It was filled out at the start of care, and then each section was filled out on a visit as it applied. But the four pages were added every time. It was easy to read, but hard to store."
The nurses took the form back and made some alterations to the form that cut it to two pages. In the first version, there was ample room for nurses to write notes. In the second version, that room was cut, and the terser checklist format was used. The second version also has clearer headings, which allows nurses to more quickly find the section they are concerned with - for instance, cardiovascular, or neurosensory. (For more on specific changes to documents, see the story above.)
The new documents were launched in April 1996, six months after the project started. But there were still changes ahead. For instance, in the first edition of the new nursing assessment form, the section on DNR had a place to check for instructions and information given. "But when we looked at the chart, we were still not clear whether it was just discussed, or if the patient had information," she says. A newer version has a section to mark if an advance directive has been executed, or if one has not. If not, the nurse must make clear whether it is because the issue is pending, or because the patient is not interested.
There were also opinions to change, says Thomas. "Change is difficult, and even though the nurses wanted less paperwork, they were still wary of the new system," she says. "Some just stated flatly that it wouldn't work - not for any concrete reason, but out of fear."
Thomas says it took about six months for them to come around. "It was a long learning curve. They were used to writing narratives and still wanted to do so. But when we audited their charts, we took them individually and coached them on how to use the system."
One of the main goals of the new documentation was to increase productivity among the nurses, cutting overtime among them and reaching an average productivity level of 5.5 visits per day. Thomas says when the new documentation came into effect, the direct and indirect time spent on each case was about even. Now, it is about 80% direct time and 20% indirect; overtime has virtually ended, and nurses are making 5.5 to six visits per day.
Thomas says she has no specific information on how much money St. Peter's has saved, but she knows nurses are not coming in on weekends any more to do paperwork, nor are they taking as much home with them at night.
Another benefit of the new forms is increased uniformity, Thomas says. "We wanted to be able to see where a patient was no matter who filled out the charts." The focus on checklists rather than exposition made that goal attainable.
Perhaps the most surprising result of the new forms was a decrease in length of stay, which in early 1996 averaged 46 days, and went down to 40 by the third quarter of that year. Thomas says some patients are being discharged 10 days sooner than they would have been in the old process because charts are easier to read. "We can better tell where a patient is," she says. "We are not missing so many opportunities for discharge because the documentation is unclear or hard to read."
Reaction from Joint Commission surveyors has been positive. "We had a survey last August, and when they came in, I asked what they thought of the documentation," says Thomas. The response was an acknowledgment that St. Peter's made a major effort to meet the standards, that the agency knew the standards, and that the organization was trying to maintain compliance with staff. "It was quite a compliment."
There were similar kudos from the Department of Health, she says. Auditors said that while they couldn't comment on specific changes to make in the new documents, it was obvious that St. Peter's was making a concerted effort to improve its forms.
If she were starting over, Thomas says she would try educating the nursing staff first on outcomes charting. "We rolled out the system without them understanding the purpose of the system. Some would try to take treatment codes and go backward to identify a desired outcome or problem, not the other way around. I think in doing it again, I would do an inservice on the principle of outcomes charting and bring out the system."
The next step in the process is to computerize. "We knew that whatever we did, it had to look to the future," says Thomas. Happily, her nursing staff is more enthusiastic about this change. "We have five nursing teams, and they had to take a vote to decide who would pilot the computerized documentation," she says. "I figured no one would want to, but they all did. It was hard to pick a team, and I think that was because they saw the benefit of the new system."
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