Michael O'Toole

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	The reality in today’s healthcare organizations is that physicians and nurses spend more time documenting in electronic health records (EHRs) and less time at the bedside with patients and families. 

Michael O'TooleIn a recent patient experience study by 

, the global network of quality improvement professionals, 47% of healthcare quality experts said that payment and regulatory systems, which are documentation-heavy and lead to reduced time with patients, are their top hurdle in improving the patient experience.

Read: Improve communication at your healthcare system: 3 tips

	When nurses and providers have their faces buried in a computer screen typing away instead of listening carefully to a patient’s concerns, EHRs can become an obstacle to effective communication, including critical eye contact and body language.

	Still, accurate electronic health records are of paramount importance for a successful health system.   

Here are four basic steps healthcare organizations can take to reduce clinical documentation time so nurses and physicians can spend more time at the bedside:

1. Conduct a time study of your clinical staff.  

First, it’s important to understand how nurses and providers spend their time.  This is best accomplished by using a tool industrial engineers have been using since the 1950s:  a time study.  Conducting a time study involves following a nurse or provider over their entire shift, documenting each task and how much time they spend on each task.  It is generally best to follow a few staff on the various shifts (A.M., P.M., weekday, weekend) to get a good picture of where the care team members are spending their time.  The Institute for Healthcare Improvement has a great 

 and template that is specific to healthcare. 

2. Identify value-added and non-value-added activities.

  Value-added activities include those that improve the patient’s health or those that the patient is willing to pay for.  Non-value-added activities take time away from patient care, do not transform the patient’s health and include regulatory activities that take time away from completing patient-focused tasks.  Summarize the tasks identified in Step 1 and categorize them into value-added and non-value-added activities.  The key is to minimize or eliminate the non-valued-added activities and maximize the value-added activities.

3. Redesign the work flow by reassigning activities to more appropriate resources.  

Many times, you will identify several nursing or physician activities that could be delegated to a more appropriate resource, freeing up time to spend with patients.  For example, many hospitals have started using medical scribes to relieve providers from the "administrative" burden of clinical documentation, particularly in fast-paced, time-critical areas like the emergency department.  Other health systems have increased their utilization of advanced practice providers and patient-care techs to allow nurses and physicians to work to the top of their license. 

Consider tools like pre-loaded documentation templates that act like forms and are built into the EHR.  For example, when a physician needs to document discharge notes for a patient, he can simply pull up the documentation template in the EHR which reminds him of all the required elements for the discharge notes.  In addition, many hospitals use speech recognition software that fully integrates with the EHR to streamline documentation. 

	Automation can also help.  For example, one of the Joint Commission’s core measures requires that patients receive specific discharge instructions if they had a confirmed blood clot and are discharged on Warfarin (a blood thinner).  Instead of requiring nurses to remember to manually add these instructions to the discharge notes, use the EHR to set up a rule by which specific discharge instructions are automatically added to the discharge notes if a patient has a confirmed blood clot and is taking Warfarin. 

	Finally, the technology solution can be very simple.  Purchasing silent-typing keyboards for population health call centers helps ensure patients that their nurse navigator is actively listening.  Hearing clicking and clacking of a keyboard over the phone gives an impression that the nurse navigator is “doing other things.”

Michael O'Toole is an industrial and systems engineer and lean six sigma instructor who has spent the last 10 years working with healthcare systems all over the country implementing various performance improvement programs.   He is currently Executive Director, Project Management at Piedmont Healthcare.

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