Electronic Health Records: Proactive Risk Assessment for Hospitals
Most healthcare organizations are moving to an electronic health record (EHR), and for good reason. With the right EHR process in place organizations can streamline healthcare services to drive operational efficiency. The EHR is also designed to reduce errors and provide safer care.
Yet, far too often when an organization embarks on the journey to implement electronic health records, responsibilities can be shifted or forgotten. Without the involvement of key stakeholders, staff often need to create workarounds that create risk to patient safety. Front line staff should be included to ensure processes are developed for ease and efficiency of use.
Digital transformations are challenging in every industry and take on various forms, like customer experience, quality, workflow and efficiency. Hospitals have the added layer to factor into any organizational change – the critical element of patient safety.
It can be helpful to look at this journey across three levels of your organization: your initiatives, your leadership, and your organization’s vision. Each level brings a different lens to the potential risks that could occur when key stakeholders are not involved in the development of the EHR. Initiatives should include regulatory compliance, patient and staff experience, availability of resources (human, financial, and physical), and streamlined communication. Leadership should be engaged in assessing whether any recommended practice affects the healthcare organization’s ability to deliver safe, effective, and high-quality care. The organization’s mission, vision, and values should be incorporated into the culture that fosters safety as a priority for everyone who works in the hospital.
Organizations may think their electronic health record process is designed to minimize potential harm that patients could receive, only to be disappointed upon learning they have unidentified safety risks when a patient safety event happens or during an accreditation survey. To mitigate safety hazards and known risks, we recommend proactive risk assessments that address specific areas that may require adjustment of the EHR configuration parameters.
We recommend looking into three common risk areas:
Policy requirements vs. actual systems and processes
The first major risk area is that the actual systems and processes in place to capture EHRs do not match the organization’s policy requirements. It is not a coincidence that the first thing surveyors do when they come to your organization is look through a list of documents you have prepared that include numerous policies. They want to know what the organization requires staff to do and document. Then they want to ensure staff are incorporating policy requirements into their workflow and not creating workarounds.
For instance, if an order is placed to titrate a drip to keep the Richmond Agitation-Sedation Scale (RASS) at a -2, the survey team will look for the documentation that supports the titration order. Far too often, surveyors find that key elements such as RASS are either not built into the system at all for the nurse to document, or nurses are expected to navigate to another screen to document this component. Having the nurse toggle between multiple screens can be a risk to patient safety. There is also an increased probability that the nurse will assess the scale but not remember to document it because the documentation is not located in a place that mimics the required workflow.
Variation in electronic health record documentation
The second common risk to patient safety has to do with variation. Have you ever heard the old saying, variation is the enemy? During the survey process, it can be. Accrediting agencies do not require or recommend a specific format for health records. At the time of survey, health records are evaluated on consent based on the defined standards of the accrediting agency. However, when surveyors review an EHR, they are looking for consistency in documentation across the organization. If each department has its own approach to documenting an EHR, it can be a red flag for surveyors.
One example could be the documentation for a time out. In one area of your organization, a nurse might record a time out as “correct patient, correct site, correct procedure.” Yet in another department, a nurse might record it as “time out completed.” A surveyor will notice the difference in documentation styles and refer to your organization’s policy to see which is correct.
Standardization across all areas of your organization ensures that required elements are made clear to staff and practitioners. Wrong-site, wrong-patient, and wrong-procedure surgery continues to be one of the most frequently reported events voluntarily reported to the Joint Commission, with 98 reported events in 2018. High-reliability organizations reduce the variability within their documentation to achieve zero harm.
Staff confidence in electronic health record processes
Even though you may have identified and addressed risk areas and hazards, your organization’s EHR process is only as good as your staff’s ability to confidently navigate that process. Patient care can be impacted if nurses forget crucial steps due to uncertainty or missing key details from patients during documentation. Significant value is added (such as strengthened workflows) in getting others involved during the risk assessment.
Keep in mind that during a survey your staff will be reviewing health records retrospectively with the surveyor in some cases. This can be very difficult if staff are not used to looking at a record in this environment. Staff might also be uncomfortable navigating the record if the surveyors requested item was documented in a different department. The survey process will go smoother if staff are able to navigate the record with confidence and ease. Consider nominating someone on staff to be a “super user,” available to assist staff with navigating the record to locate surveyor requested information.
Practice tracers are an excellent way for your staff to gain the confidence they need to locate the following key documents:
- History and physical exam
- Initial nursing assessment and physical exam
- Pain assessments and reassessments after interventions
- Screenings for suicide risk, including in-depth assessment and appropriate interventions if positive
- Falls risks and interventions taken
- Care plans
- Physicians’ orders
- Medication administration record
- Informed consents
- Operative report (immediate note and official report)
- Pre-anesthesia assessment, anesthesia record, and post-anesthesia assessment
- Restraint assessments/monitors
- Blood transfusion records
- Dialysis records
- Discharge plans
Minimizing safety risks and ensuring compliance
Is your electronic health record process built to minimize safety risks and ensure compliance with required documentation elements? The best way to test your organization’s readiness is to pull records throughout the organization on various topics. For instance, if invasive procedures are performed in numerous areas, then pull one from each area and look for instances when staff have not documented according to the policy, and for variation in charting practices.
If you notice you have a variation, we can help you fine-tune your EHR to ensure it is driving continuous performance improvement. We will partner with you to support your staff along that journey so that your organization thrives without us. Our goal is the same as yours: to provide safe, quality care for the people who matter most—your patients.
To discuss how TiER1 Healthcare can help your team form a complete approach to providing a safe and effective care environment, contact us at (800) 241-0142 or firstname.lastname@example.org for a consultation.