Nursing has come a long way. The recent proliferation of wireless technologies in the hospital has changed the face of nursing, replacing clipboards with computers on wheels, and phones with hands-free badges. And it isn't just the gadgets; nurses are more tech-savvy than in the past, and many are carving out key roles on the CIO's strategic team.
As wireless devices become increasingly common and assume a greater role in the care process, the onus is on hospital leaders to select technologies that can improve nurses' work by enhancing communication and workflow efficiency.
“We recognize that technology gives us an opportunity to improve upon the care that we deliver and to make our clinicians' lives easier. So we try to implement technology when we believe it can do those things,” says Daniel Nigrin, M.D., senior vice president for information services and CIO at Children's Hospital Boston.
The first step in doing that, says Fran Turisco, research principal in the Waltham, Mass.-based Emerging Practices Healthcare Group of CSC (Falls Church, Va.), is to identify the biggest hurdles nurses face. “There's a lot of pressure. You have to do things on time and you have to do them right the first time, and the patient has to have a safe, high-quality experience. I think nurses have one of the toughest jobs around,” says Turisco, who co-authored a report in 2008 with CSC Senior Research Analyst Jared Rhoads detailing the challenges nurses face.
According to their research, one of the most significant barriers to care delivery is communication. Nurses, says Turisco, are often placed in the middle of the communication loop, where they constantly receive and place calls to physicians, pharmacy and lab, all while trying to tend to patients.
“So the issue is how you cut out some of the middle men in these communication loops,” she says. “And how do you shorten the timeframe between when a nurse needs to talk to someone and when she actually gets to talk to that person, then either make a care decision or figure out what needs to get done next.”
At University Hospitals Case Medical Center in Cleveland, leadership addressed the problem by rolling out hands-free communication systems from San Jose, Calif.-based Vocera in the NICU. The technology enabled clinicians to call for assistance or answer pages by using a voice recognition button.
With the badges, which run on the hospital's wireless platform, nurses “can call for help or communicate with colleagues across departments,” says Mary Alice Annecharico, M.S., senior vice president and CIO at University Hospitals. The technology, she says, is scalable to expand the system to other units throughout the 1,032-bed academic medical center and tertiary-care hospital. “We're considering using it in the OR and other areas where critical action is required in brief periods of time. It's easy to use, it's instantaneous and it's been a technology improvement that we've been able to deliver with our internal skills and capabilities.”
Turisco says, by facilitating communication with other clinicians, tools like the Vocera badge enable nurses to more effectively manage multiple tasks.
Turisco says the technology enables nurses to prioritize the work that needs attention and classify things in terms of what's critical, what's important, and what can be done in a more reasonable timeframe. And when voice over IP is integrated with monitoring systems or information from laboratory or order systems, Turisco says it is enhanced even more. “It adds an additional layer of information that helps nurses decipher what needs attention now and what must be escalated to a physician,” she says.
Another common theme found throughout Turisco and Rhoads' report is workflow issues. A number of organizations are addressing the problem by deploying patient flow systems to provide nurses with improved visibility of both bed availability and patient status. With these solutions, instead of making several calls and chasing down charts, nurses can look at a screen to find out what rooms are available, how long patients have been waiting to see a physician, and when patients need to be turned.
Some systems even indicate core measures using certain codes. “It pulls all the information that nurses might try to carry around in their heads and puts it at a visual level,” says Rhoads.
According to Eileen Sporing, CNO at Children's Hospital Boston, improving workflow was one of the organization's top priorities when it rolled out the Farmington, Conn.-based Premise Patient Flow Platform in 2008. Since going live, Sporing says, the system has helped eliminate what she calls “time wasters” from the care process. Now, she says, “We know exactly how long it takes to identify where capacity is and how we can get patients moved as quickly as possible. We've eliminated all of the manual processes, and that's been enormously satisfying.”
One of the biggest selling points for patient flow systems, according to Turisco, is the ease of use factor. “It's one of these technologies that you almost think is too good to be true because it's not that hard to install. You can configure it in a short period of time to do exactly what you want.”
According to Rhoads, a number of organizations have taken the system a step further and configured it to display information for environmental services as well, making it even more valuable for staff. “You're decentralizing the decision process so housekeeping doesn't have to constantly ask which room needs to be cleaned next,” he says. “It's an easy system to put in, and it's fairly passive. It's just taking data that already exists and making it usable. You don't have to interrupt your own workflow, sit down at a workstation, log in and try to look up something.”
While organizations may differ on some of the goals they hope to achieve in implementing wireless technologies, the one driver they all share is improved patient safety. And the technology many hospitals are leveraging to reduce errors is bar-coded medication administration.
Children's Hospital Boston is currently piloting bar coding in three units, using handheld technology from Kansas City, Mo.-based Cerner. According to Nigrin, positive results were achieved so quickly that plans are in place to extend it to additional units in the 397-bed hospital.
“We've already seen some pretty impressive ‘good catches’ where the device fires off an alert that a medication was about to be given inappropriately to a patient,” says Nigrin. “The point of administration is one in which we know that errors occur, and that's the last point where you're going to be able to intervene before a medication is given inappropriately. So we think it's very important.”
At University Hospitals, Annecharico's staff has embraced bar coding - not just for the safety component, but also for its ability to improve workflow efficiency. “It's a mechanism for us to deliver critical information at the point of care as rapidly as possible, so you don't need to go back to charts or other sources to understand how you're going to administer therapy to a patient,” she says. “It eases the burden of responsibility for a clinician to know what they need to do when they need to do it.”
Creating a better environment for nurses, however, doesn't have to mean putting in new systems. It can also mean making improvements to existing ones.
Memorial University Medical Center in Savannah, Ga., is undergoing a major upgrade to its nursing documentation system from Alpharetta, Ga.-based McKesson. According to Senior Vice President and CIO Patty Lavely, nurses at the 530-bed academic medical center had been using the system for so long that the screens became too cluttered by fields added to meet Joint Commission requirements or other quality initiatives. It was in dire need of a face lift, she says. “So we sat down with nurses from each area and each service line, looked at their documentation requirements and their workflow, and designed screens to better support them.”
The goal, Lavely says, is to reduce time to document by 15 percent, allowing nurses more time with patients which, in turn, can boost staff satisfaction. “We're hoping that when we upgrade the system, it will take them less time, and it will be easier and more intuitive.”
Lavely is confident Memorial University will be able to achieve its goals, largely because nursing is actively involved, as is the case with most projects, she says.
In terms of governance, the organization has a clinical systems steering committee that includes the CNO and two nursing directors, along with the vice president of quality, who is a physician. There is also a nursing director who specializes in patient care, and another who works closely with information services on all technology initiatives. And while the clinical systems group doesn't select technologies directly, it does provide a recommendation to the executive committee, says Lavely.
Similarly, the governance policy at University Hospital employs a multidisciplinary approach in selecting technologies that requires stakeholders from various areas to collaborate with IT, analytic teams and project managers.
And Nursing, says Annecharico, “is at the table. They are the drivers. We've been very successful, largely because I think we're a very listening organization. We pay close attention to what is needed, rather than the next bells and whistles that technology can deliver.”
Nigrin, who has served as CIO at Children's for eight years, says it is critical to involve nursing in the planning and rolling out of technologies. “One thing we recognized early on is that any IT project, whether it's clinical or non-clinical, is dead in the water if you don't involve your stakeholders throughout the entire process,” he says.
At Children's, which has adopted a “shared leadership model,” executives engage clinicians and clinical leaders from nursing in key projects, from the initial idea and RFP all the way through the implementation. “I think many institutions don't recognize the impact that rollouts have on nursing workflows and nursing processes, and it's absolutely critical that you involve the nursing organization when you do these things if you're hoping for success,” he says.
Nurturing the CIO-Nurse Relationship
Mary Alice Annecharico
As a CIO who is also a nurse, Mary Alice Annecharico, M.S., of University Hospitals of Cleveland, knows what it's like to walk in nurses' shoes. But for CIOs who don't share her experiences, she offers some advice on how to form a strategic partnership with those who practice care on the front lines.
“There is no better ally in an organization than the nursing community. So for those that don't have the background or experience to understand what nurses go through, it's very important to invest the time to engage the nurses and to involve other cli nicians that may be on your staff, to take a lead in supporting that relationship and developing it. One of my guiding principles has always been that regardless of the setting, if you actively engage in listening to what our user population needs, they'll tell you. Engage all of the right people to help define and refine what those needs are, and embrace the challenges in a way that you create satisfiers rather than barriers.
“Many CIOs who don't come from a clinical environment are absolutely afraid of nurses. But as most of us know, nurses don't bite. They may feel very strongly about some things that are important to them, but it's just a new opportunity for new relationships when CIOs don't come from a clinical perspective. We need to stop acting as if we're working in silos that are separate and apart from one another. In most organizations today, in order for IT to be successful, it must really be a service line that is accountable and responsible to all divisions, including nursing. So if we think about that as being service-oriented, it erases so many of those barriers that are otherwise there.” - K.G.
The proliferation of wireless technologies in the hospital setting has significantly impacted the way nurses deliver care.
The primary goals CIOs are looking to achieve in implementing wireless technologies are to improve communication, workflow efficiency and patient safety.
Organizations that have successfully implemented wireless technologies have had nursing leaders involved in every key step of the process.
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Healthcare Informatics 2009 September;26(9):30-33