Electronic health records (EHR) have improved interdisciplinary communication, but poor usability and functionality make it difficult for nurses to assimilate clinical information to improve care coordination. During a typical shift, RNs provide clinical care to patients, but unfortunately, they spend a large portion of their time documenting care to meet multiple requirements, whether it be regulatory standards, reimbursement, or quality metrics. Documentation of care delivery is necessary. However, it's primarily data entry, and the volume is often considered burdensome, redundant, and repetitive, resulting in decreased satisfaction.1-3
Nursing is the nation's largest healthcare profession with a 15% projected growth from 2016 to 2026.4 Unfortunately, the global pandemic has contributed to high turnover rates and staffing challenges that are expected to continue in the foreseeable future. Prior to the pandemic, the US Bureau of Labor Statistics projected 194,500 RN vacancies from 2020 to 2030.5 These numbers don't account for the increased retirements attributed to the pandemic, making the projected 15% growth rate insufficient to close the gap in the nursing workforce. The topic is of significant interest as the nursing profession continues to face these staffing shortages and the increased demands highly acute patients place on nurses. Considering the current state and future workforce projections, it's critical to review practices that impact nursing workload, such as nursing documentation.
Documentation accounts for a substantial number of nurses' duties but is considered burdensome. Duplication is typical and associated with negative attitudes toward documentation.6,7 The literature doesn't indicate if the documentation activities themselves or the time spent completing documentation is associated with nurses' perceptions of workload.8 Recent studies suggest that nurses employed in the US spend 26%-41% of their shift handling documentation.9,10 Roumeliotis and colleagues identified nurses spend approximately one-quarter to greater than one-third of EHR time on documentation and document one data point per minute.9,11
Diminishing the time nurses spend on documentation through optimization redesign can decrease non-value-added tasks, impact efficiency, improve satisfaction, and reduce the workload-associated burden.8 The COVID-19 global pandemic is a prime example of a situation that prompted collaboration among health systems and national organizations (such as the Alliance for Nursing Informatics, the American Nurses Association, American Nursing Informatics Association, and the American Medical Informatics Association) to address the crisis by identifying minimum nursing documentation requirements.12 Healthcare leaders evaluated existing practices and policies to reduce documentation, improve efficiency, and configure new workflows during times of crisis while adhering to regulatory requirements. The purpose of this article is to describe a successful documentation redesign to decrease nursing reassessment documentation time at an academic healthcare system using Kotter's change management theory.
Background
An academic healthcare system in North Carolina found that nurses were spending approximately 23% of a 12-hour shift on documentation versus valuable direct patient care.13 Although this percentage is lower than the average 26.2%-41% identified in studies, health system nursing leadership prioritized exploring opportunities to optimize nursing documentation to enhance care delivery and improve staff satisfaction and well-being.9,10
Healthcare systems are complex organizations with ongoing rapid cycles of change. Initiating sustainable change is vital to operational success but is challenging for leaders. To be successful, leaders should use a change leadership theoretical model as a foundational approach to implement and sustain change. John Kotter's change management theory is recognized as a successful change framework widely used in healthcare and empirically supported to assist employees' transition through change.
Kotter believes organizational change is accomplished through a dynamic, influential, nonlinear, eight-step approach encouraging collaboration and engagement.14 The eight steps described in Table 1 are sequential and organized into three distinct phases. The first phase (creating a climate for change) includes steps 1-3; the second phase (engaging and enabling the organization) consists of steps 4-6; and the third phase (implementing and sustaining changes) includes steps 7 and 8.14 Kotter's model is structured, highly effective, easy to apply, and includes interventions to tackle the multitude of emotions and behaviors staff may exhibit as they evolve through the change. Inspiring and motivating staff through "mind and heart" compels them to act and engage in the change.14 Facts and data are tools to identify the problem but relating to staff through empathy and emotions leads to trust, pride, urgency, and hope. Staff members need to think and feel positively about the change for change to occur.
Phase 1: Create an environment for change
Step 1: Create a sense of urgency
Change initiatives may fail if key stakeholders (in this case, frontline staff who are end users of the EHR) aren't engaged. Studies show 70% of change fails because of employee resistance and lack of leader support, whereas change is 30% more likely to stick if employees are engaged.15 Kotter found that 75% of staff need to support the change for it to be successful.16 Leaders need to create a sense of urgency to get teams' attention and convince them of the importance of changing as well as the consequences of not changing.
The initial step in the redesign process was to identify the problem of time spent on documentation as an "opportunity" for positive change. The associate CNO (ACNO) and the Chief Nursing Informatics Officer (CNIO) created a sense of urgency by communicating vendor EHR timestamp data and the results of a health system nursing survey that identified nurses' perceptions of documentation. The vendor timestamp audit logs, called the Nursing Efficiency and Assessment Tool (NEAT), denote time in minutes spent on nursing documentation during a typical shift or patient visit. The NEAT data showed that nurses spent 162 minutes active time per 12-hour shift across the healthcare system and 58 minutes in flow sheets.
An electronic survey was distributed to direct care RNs in all areas of the healthcare system, including inpatient, procedural, ambulatory, and perioperative services, to obtain feedback and identify recommendations of RNs. The survey was deemed exempt by the Duke University Health System Institutional Review Board and was considered a quality improvement study. Survey completion implied consent. According to the survey results, nurses perceived that they dedicated 43% of their shift to documentation and 45% of the documentation was unnecessary and present elsewhere in the EHR. These survey findings, along with the NEAT data, provided the impetus to embark on the performance improvement journey to address time spent on nursing documentation.
Step 2: Form a guiding coalition
According to Bozak, employees are more likely to support a change if they understand the benefits of electronic documentation and are actively involved during the planning and implementation process.17 The ACNO, a nursing leader designated as the project lead, solicited stakeholders from nursing leadership and frontline nursing staff from the adult and pediatric inpatient units, ambulatory, procedural, and operative settings to engage in the planning and implementation of the quality initiative. The ACNO established and facilitated a committee and partnered with the CNIO; both possessed the knowledge, skills, and ability to influence, persuade, and adopt practice change to redesign nursing documentation. Together, the ACNO and CNIO brought visibility to the problem and advocated for change.
Committee meetings were structured using the health system professional governance model designed to achieve excellent outcomes consistent with nursing values and expectations grounded in caring practice: integrity, excellence, innovation, and collaboration. A shared governance model approach was enacted for shared decision-making among professional nurses and organizational leadership. Guiding principles were developed to support safety and efficiency and foster alignment with the health system's nursing strategic plan goal to improve coordination and communication of patient care across the continuum. The committee reviewed and approved the guiding principles with the expectation to respect all opinions and consider all feedback. Decisions would be made with appropriate representation of clinicians, disciplines, and facilities.
Step 3: Create a vision for change
The third step is to create a vision that staff can comprehend and remember. The vision drives the change by simplifying complex processes, motivating stakeholders, and developing strategic initiatives to achieve the vision. An objective of the health system's strategic plan focused on innovative technology with the goal to explore opportunities to improve/optimize nursing documentation not limited to technology, processes, people, and tools to enhance clinician and patient well-being. The vision of this quality improvement study was to redesign nursing flow sheet documentation using a professional practice approach to decrease time spent on nursing documentation. The nursing survey results identified the specific area to address in the redesign process to ensure the scope of the project was achievable.
Phase 2: Engage and enable the organization
Step 4: Rally and communicate the vision
Once the vision was established, the message needed to be shared with those helping to execute the plan. A shared vision is imperative at the individual and team level to contribute to the organization's goals, or in this project, the health system's goals. Communicating how individual nurses contributed to the health system's success demonstrated that they were vital members of the process and made them feel valued. Valued employees become engaged employees and partners in success.
The ACNO project lead communicated the vision through a multitude of channels including: the Chief Nurse Executive (CNE) monthly newsletter; weekly and monthly presentations at health system nursing leadership councils, frontline staff health system clinical practice councils, nursing informatics council (NIC), and departmental staff meetings; and one-on-one meetings conducted during rounds. The vision was reinforced frequently through daily unit rounds and attendance at the monthly aforementioned councils. Staff members began to embrace the vision for change and volunteered to participate on the documentation committee.
Step 5: Enable action to achieve the vision
To ensure staff buy-in, frontline staff need autonomy and empowerment to act. Four open forums were conducted to obtain staff feedback and recommendations. The forums and nursing survey identified the reassessment documentation as the focus. Staff recommendations were built into the EHR playground environment to determine if the proposal was more efficient for the teams. The committee agreed to rearrangement of content, removal of rows, and implementation of a practice change to only document reassessment changes in the body systems that had a change from the initial assessment. This process removed barriers, decreased duplication, improved workflow, and demonstrated the proposed changes would decrease documentation time and burden. The rearrangement, removal, and practice change were supported by health system nursing leadership.
Step 6: Create short-term wins
Creating visible short-term wins that are clearly connected to the change effort builds momentum for future action items.16 Five quick wins based on staff feedback from the nursing survey and open forums were implemented and quickly moved to production. Quick wins included moving sections to better align with nursing workflow, which decreased the click-and-scroll burden improving efficiency. Specifically, the five quick wins included: 1) moving the repositioning/transport group to purposeful rounding/safety checks; 2) removing multiple rows for notification of provider because this was documented in other sections of the EHR; 3) removing family/visitor behaviors because they're not pertinent for patient care; 4) moving anus/rectum to the gastrointestinal group for improved workflow; and 5) removing documentation rows that were located in other sections of the EHR. These quick wins were implemented within the first 2 months of the committee development, and staff members were grateful for the changes, which aligned with nursing workflow.
To capitalize on the quick wins and integrate the reassessment documentation change and associated behaviors into the culture, the ACNO project lead rounded on the units multiple times per week on all shifts including days, nights, and weekends. The visibility promoted communication and reinforcement of the quick wins, education, and real-time feedback. This was well received by the team because immediate coaching was provided. Adherence with the changes was maintained and reinforced, keeping the vision in focus. This success provided a momentum for future changes.
Phase 3: Implementing and sustaining change
Steps 7 and 8: Build on the change and anchor it into the culture
A compelling aspect of change management is to create lasting change. Sustainability of change is difficult because people tend to revert to old habits and practices. A sustainability plan included feedback at the individual, department, and health system levels. Individual feedback was provided to staff during rounds. Department and facility vendor-supplied timestamp data was reviewed at the health system NIC and the nurse executive council, and disseminated through the CNE newsletter. They also continued to review NEAT metrics on a quarterly basis at minimum at the NIC, documentation committee, and nurse executive council. The revisions to documentation were incorporated into the health system onboarding training process for new hire and preceptor orientation. To decrease time and burden, the NIC continues to make changes to documentation based on the nursing survey and feedback provided by staff who attend the NIC.
Outcomes
The revisions to nursing reassessment documentation resulted in a considerable decrease in active time in minutes per 12-hour shift. The time prior to the revisions was 162 minutes. The February-April 2022 NEAT data reflected 129 minutes, a 20% decrease in documentation time. The time spent in flow sheets decreased from 58 minutes preintervention to 50 minutes, a 13% decrease. The time is anticipated to decrease further as the committee continues to prioritize interventions to meet the overarching vision. Each additional minute saved is time that can be spent in direct patient care. Anecdotal comments from nursing staff indicated that documentation is easier, faster, and more focused. Staff also conveyed that it was easier to spot changes from previous documentation and they didn't have to rechart the same information, which saved significant time each shift.
Continued and sustained change
The success of this quality improvement practice change initiative has implications for other healthcare institutions. A change model is vital when embarking on change, especially in healthcare. Healthcare is undergoing incredible change due to technologic innovation, evolving regulatory considerations, and major staffing shortages. Using a change model framework provides structure and guidance to ensure change is successful and sustainable.
Kotter's change model provided an effective and practical framework to create sustainable change in nursing documentation workflow redesign. The model was simplistic and methodical for nurse leaders and engaged and empowered staff to contribute to the change vision. Key stakeholder selection was necessary to ensure leadership endorsement and staff participation. Motivating the team members led to engaged staff who incorporated the change as the new norm and standard.
Future quality improvement projects pertaining to nursing documentation redesign are forthcoming. The projects will focus on decreasing the burden of documentation in priority areas based upon the nursing survey, open forums, and the NIC. The focus areas include daily cares and safety and intake and output. These two areas will contribute to substantial changes and require a change leadership model. Kotter's change leadership model is an effective model that can be used for successful change.
INSTRUCTIONS A shared governance approach to nursing documentation redesign using Kotter's change management model
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