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Hawaii Pacific Health is a nonprofit health care system in Honolulu with approximately 1400 employed physicians, including both academic and independent physicians. They are one of the largest non-governmental employers in the state of Hawaii.
The Hawaii Pacific Health System's EHR had been in use for 10 years, and over time a number of tools and documentation tasks within it had been added or modified. As is the case within many organizations, it became evident that the EHR needed improvements.
Specific problems included:
Habitual clicking posed a risk to patient care. Because of the large number of meaningless clicks required in the EHR, clinicians were mindlessly clicking things that appeared on the screen to make it go away or to move on to the next task more quickly. For example, nurses were routinely choosing “no” when the EHR asked whether it was likely the patient had an infection, when the next action taken was documenting signs and symptoms of infection. In another instance, a resident clicked an alert to move on, but failed to realize that it was a warning for serious medication risk.
Clinicians were not optimally using the features of the EHR. The extra time spent on the EHR resulted in less time for patient-provider interactions.
Potentially decreased employee morale as a result of these EHR challenges.
Melinda Ashton, MD, Chief Quality Officer at Hawaii Pacific Health, recognized that many of the time-consuming tasks in the EHR were not a result of the technology itself, but the organization's overall approach to documentation. Dr Ashton and her team set out to look for areas where documentation could be simplified or made easier for the entire care team. The concerns were presented to the Hawaii Pacific Health executive team, who were supportive of trying a new initiative to decrease the demands of documentation by eliminating unnecessary tasks.
In the discussion, some on the team wanted to call it what everyone thought it was: stupid stuff. One person came up with the name “Getting Rid of Stupid Stuff” (GROSS for short). Shortly thereafter, they launched the “Getting Rid of Stupid Stuff” campaign across Hawaii Pacific Health. To create awareness, the program was presented across their health system at internal meetings, in newsletters, and other various communication channels.
The GROSS team created an electronic system that allowed employees to submit EHR issues and improvement ideas. They asked all employees to look at their daily documentation experience and nominate anything in the EHR that they thought was poorly designed, unnecessary, or just plain stupid.
The submissions were monitored by a small group of employees who acknowledged receipt of the suggestions, and either fixed the issue or triaged the request. Minor requests were fixed immediately, while suggestions that required a deeper analysis were sent to an appropriate (often discipline- or specialty-specific) EHR workgroup that was charge of considering and recommending the change.
The team categorized the suggestions into three main groups:
Never meant to occur: Unnecessary documentation tasks that were never meant for a specific patient population.
Needed, but could be more efficient: Documentation that was necessary, but could be done in a better way.
Required, but not understood: Documentation tools that are required, but users were unaware that a requirement existed or did not know how to use it.
When the team first began to present their intervention at various leadership meetings, it was often met with sheepish laughter. There was slight pushback as they began to implement modifications to the EHR, as providers had to adjust to changes that impacted daily documentation. However, as they continued to execute their plan, it became apparent that providers were enthusiastic about their efforts. The executive team has acknowledged their success, and encouraged their leaders to continue to promote the GROSS program.
To date, there have been more than 450 total submissions. About 10% were “never meant to occur”, 75% were “needed, but could be more efficient”, and 15% were “required, but not understood”. Many successful changes have been implemented.
One specific example of a successful change had to do with the hourly rounding requirement for nurses. Years ago, when Hawaii Pacific Health had implemented hourly rounding for hospitalized patients, it was intended that the success of the process would be measured by managers who (1) observed the staff behavior, and (2) interviewed patients about their experience. At some point, the process was changed, and the nurses were asked just to document their hourly rounding. Hawaii Pacific Health thought they were making it easy to document their hourly rounding by creating a drop-down list of choices about what had been done. The first choice on the list was “AIDET” (Acknowledge, Introduction, Duration, Explanation and Thank you), an approach to communication with patients that had been adopted within the health care system. Many of the nurses had documented that they did AIDET, but when queried about what that meant, they couldn't offer any description of what they had actually done. When the team had removed the requirement for nurses to document their hourly rounding, and asked them instead to simply continue to document the care being provided, there was a significant impact. Removing this single task saved approximately 1,700 nursing hours per month across the four hospitals, as it was timed to take a nurse on average 24 seconds to complete this task (finding the row, accessing the dropdown menu, and choosing the appropriate selection to click).
As anticipated, the team also received nominations that made it clear that they needed to do a better job of educating staff about various documentation tools. Several requests came in from physicians asking for sorting and filtering capabilities that already existed. Although Hawaii Pacific Health has long had a physician- documentation optimization team to help clinicians use the EHR efficiently, most physicians reported that they didn't have time to meet with this team.
The GROSS program has grown immensely within one year. The team has maintained a spreadsheet of nominations and outcomes. Their records indicate that they are now receiving more suggestions for improvement, rather than requests to remove stupid stuff. Recently, the team has started to focus specifically on the physicians' use of the EHR.
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