EXECUTIVE SUMMARY - University of Michigan



Improving Pressure Injury Assessment & Documentation at Michigan Medicine Inpatient Rehab FacilityFinal ReportSubmitted to:ClientAndrea HarrisOperations Manager, Inpatient Rehabilitation1500 E. Medical Center DriveOffice 1G221LAnn Arbor, MI 48109CoordinatorsJoanna Blackmer, CI SpecialistAustin Chrzanowski, CI SpecialistKevin Noble, CI Specialist777 East Eisenhower ParkwaySt. 600Ann Arbor, MI 48103LiaisonMary DuckAdministrative Support Team, Continuous Improvement777 East Eisenhower ParkwaySt. 600Ann Arbor, MI 48103Submitted by:IOE 481 Team 4Jomari GloverCaitlin DeleviePeighton ChildressGonzalo CovosDate Submitted: April 21, 2020TABLE OF CONTENTS TOC \h \u \z EXECUTIVE SUMMARY PAGEREF _5uvjrs6smeut \h 4Methodology PAGEREF _ppez353km1h \h 4Findings and Conclusions PAGEREF _nbuy0b8gcnuf \h 4Recommendations PAGEREF _oqy8do5tkrph \h 5INTRODUCTION PAGEREF _6nlcnjl3o7tg \h 7BACKGROUND AND KEY ISSUES PAGEREF _i8hsntk3mwi5 \h 7GOALS AND OBJECTIVES PAGEREF _hhfu9b44z4kc \h 8PROJECT SCOPE PAGEREF _7kki3h1gzg3y \h 9DESIGN PROCESS PAGEREF _a8atiie4ltvm \h 9Engineering Challenges PAGEREF _oz2hhy31nw4o \h 9Literature Search PAGEREF _bpl18knvlnfo \h 9Design Constraints PAGEREF _e2xsneuqybq7 \h 10Design Requirements PAGEREF _sw9etn9nmjom \h 11Deliverables PAGEREF _zdrvw7bbdtb3 \h 12DATA COLLECTION AND ANALYSIS METHODS PAGEREF _la5cnc8sn3g2 \h 12Historical Data PAGEREF _b2cpw4wgqn0c \h 12Observations PAGEREF _1d6tjfm3cxlc \h 13Interviews PAGEREF _sk2mbeu9uxo3 \h 13FINDINGS PAGEREF _u20bpgev2ia8 \h 13Historical Data PAGEREF _stjaoqmp0csv \h 13Nurse Observations PAGEREF _bakk46ja0qhg \h 14Operations Observations PAGEREF _89d613rl12yi \h 14Interviews PAGEREF _ct068be3kxg2 \h 14CONCLUSIONS PAGEREF _zgtgbydfq0u \h 14Historical Data PAGEREF _x6srd9qemcex \h 15Nurse Observations PAGEREF _7700e74eh16s \h 15Operations Observations PAGEREF _efia2ag1w98a \h 15Interviews PAGEREF _e9w64snsnmi4 \h 15RECOMMENDATIONS PAGEREF _o5reinfu0hnz \h 16Standardized Template in MiChart for Pressure Injury Documentation PAGEREF _ja9w5xqeuq88 \h 16Pressure Injury Assessment Guide PAGEREF _aohcg7srujms \h 16Include Figure of Pressure Injuries with Physician Sign Off PAGEREF _fsluu08uqayl \h 16Use Queries to Physicians as a Key Performance Indicator PAGEREF _2qmza09b36we \h 17Per Nursing’s Request PAGEREF _evgn7f5zgc2i \h 17EXPECTED IMPACT PAGEREF _9rjvyutst4db \h 17REFERENCES PAGEREF _nnqkyy75tse \h 19APPENDIX A: SET OF INTERVIEW QUESTIONS PAGEREF _4cxhlecav2m6 \h 20APPENDIX B: SAMPLE STANDARDIZED TEMPLATE FOR MICHART PAGEREF _8poag3b7i6k2 \h 21APPENDIX C: SAMPLE POCKET CARD PAGEREF _ta8ivgylfpnw \h 22APPENDIX D: PRESSURE INJURY ASSESSMENT GUIDE PAGEREF _sk23d8yg813g \h 23APPENDIX E: RECOMMENDATION PUGH MATRIX PAGEREF _vybkesgxppmb \h 24List of Tables and Figures PageFigure 1. Prescribed Process For Pressure Injury Assessment And Documentation 7Table 1. Constraints and Standards Matrix 10 Table 2. Pugh Matrix Template for This Project 11EXECUTIVE SUMMARYBackground and GoalsThe Michigan Medicine Inpatient Rehab Facility is required by the Center for Medicare and Medicaid Services to report on specific patient data items as a Quality Reporting Program (QRP) requirement and for Operations purposes. Pressure injury status at admission and discharge is one of these items. The data is also publicly reported as an indicator of quality when comparing inpatient rehab facilities. At Michigan Medicine, there is a problem with inconsistencies between nursing and physician documentation regarding pressure injuries. This not only leads to a greater risk for inaccuracies in the information being reported publicly and on Operations documents but may also account for missed opportunities for necessary patient treatment.The Operations Manager asked us to design an improved, collaborative process for nurse-physician pressure injury assessment, an improved method of pressure injury documentation that is accurate, timely, and consistent between nurses and physicians, and define a key metric to measure successful implementation and future performance of the pressure injury assessment and documentation process. In light of the COVID-19 outbreak, the deliverables were changed slightly -- instead of a completely new process, the team has provided recommendations for changes/additions to the current pressure injury assessment and documentation process. This is explained in more detail in the Deliverables sub-section of this report.MethodologyThe team completed the following steps over the course of this project:Literature search: The team identified research on what increases quality documentation, how experience plays a role in documentation, and previous IOE 481 projects regarding documentation. Analysis of historical data: The team reviewed historical data provided by Operations regarding pressure injury documentation queries in order to assess the current state of the process.Observations: The student team shadowed and observed nursing staff and the Operations department which allowed us to better understand the process and the corresponding problems. Interviews: The team held interviews with Nursing, Physician, and Operations leadership to get a holistic view of what the project needed and where they thought improvement was necessary.Development of conclusions and recommendations: Using the findings from the various methods of data collection and analysis listed above, the team explored potential changes/additions to the current pressure injury assessment and documentation process. Our final recommendations are found in the Recommendations section of this report.Findings and ConclusionsThe team analyzed historical data as well as data collected through observations and interviews to develop findings and conclusions. It is important to note due to the COVID-19 outbreak; our findings were limited to a combination of what we were able to observe previous to moving our work online as well as the research and interviews conducted.The most significant findings and conclusions are described below:The team found nurses did not know of the Operations department’s requirement for physician documentation, further demonstrating communication was poor.Even though the skin checks were being done consistently throughout the patients’ stay and there were no issues with the knowledge of staging, nurses would often note pressure injuries in different ways and in different places. Variation of language in the documentation may have caused confusion. After analyzing our literature search, the team conferred optimality is usually reached through effective standardization. Based on this, we have provided recommendations on how to implement a more standardized note-taking process than the one in place already. After analyzing different patterns in the data collected as well as creating a Pugh matrix, we found the best way to optimize communication between the nurses and physicians as well as minimize inconsistent documentation was to create weekly team meetings, which will allow for any inconsistent information to be fixed.RecommendationsEven though the COVID 19 outbreak has limited the team to conduct further observations and be more exposed to what goes on in the hospital, by using our findings and conclusions as well as extrapolating data, we developed various potential solutions for the MMIRF. The team was asked to create a “newly designed collaborative process for nurse-physician assessment of pressure injury status” and was not able to due to insufficient time and limited observations. However, we provided these potential solutions as additions or changes to the process that help ensure better communication and minimizing inconsistent documentation. Below are the following recommendations for changes/additions to the current assessment and documentation process:Adding a standardized new template in MiChart for pressure injury documentation to avoid differences in how nurses document pressure injury information. Creating a pressure injury assessment guide with pictures of the different stages of pressure injuries to improve identification, assessment, and documentation. These pictures and definitions would be based on the National Pressure Ulcer Advisory Panel. Include a figure of Pressure injuries with physician sign off. This will allow the doctors and nurses to be on the same page even if the other entity has not seen the injury yet. In addition, this will promote more efficient tracking of pressure injury progression.The team recommends the number of queries per month is used as a key metric for measuring successful implementation and subsequent performance of the pressure injury assessment and documentation. In our original alternatives that we considered, the team included specific training for pressure injury staging. We believe it may be beneficial for IRF attending physicians to receive additional training prior to starting their work. This could be further explored by future IOE 481 teams, using our project as groundwork. INTRODUCTIONThe Michigan Medicine Inpatient Rehab Facility (MMIRF) located in 6A of the University Hospital (UMH 6A) is responsible for managing rehabilitation cases related to different injuries requiring specialized plans and care. The MMIRF’s goal is to assist patients in getting get back to an independent lifestyle after leaving the unit. Whenever a patient is admitted to the MMIRF, an initial assessment is performed. Part of this initial assessment includes checking for pressure injuries and documenting any pressure injuries found. A pressure injury is a localized damage to the skin, the underlying soft tissue, or both. People who are limited in their ability to change positions are especially at risk for pressure injuries, so they can be very common in the MMIRF. Pressure injuries can become very serious wounds, sometimes penetrating as deep as the muscle and bone.Pressure injury documentation is used for patient care purposes as well as coding and Operations purposes, and the Operations Department has noticed a considerable amount of inconsistencies within and between documentation of pressure injuries by nurses and physicians. In addition, inconsistencies in documentation affect the information regarding pressure injuries the MMIRF must report as required by the Center for Medicare and Medicaid Services and as part of the Quality Reporting Program.The Operations Manager of the MMIRF expressed concerns surrounding the current pressure injury assessment and documentation process being inefficient and a disconnect between the work being done by nurses, physicians, and other hospital entities. As a result, the Operations Manager asked us to design an improved, collaborative process for nurse-physician pressure injury assessment, an improved method of pressure injury documentation that is accurate, timely, and consistent between nurses and physicians, and define a key metric to measure successful implementation and future performance of the pressure injury assessment and documentation process. This final report presents the design process we used for this project, our data collection and analysis accomplishments, and our findings, conclusions, and recommendations for pressure injury assessment and documentation in the MMIRF.BACKGROUND AND KEY ISSUESPressure injury documentation accuracy and consistency are very important to the MMIRF and to Michigan Medicine as a whole. The health of the patients is the number one priority and they should be leaving in a better condition than when they first come in. Operations accuracy, quality data reporting, and facility reputation are other large motivators for improving documentation accuracy. Assessing and documenting pressure injuries accurately is necessary to ensure patients are being treated properly, billing coding and Operations’ documentation is done correctly and without extra work to verify inconsistencies, and the facility’s reputation is maintained (as pressure injury statistics are available to the public).Currently, patients are to be assessed from head to toe within 24 hours upon admission. This assessment includes a “skin check”, part of which includes identifying and staging any pressure injuries. According to the Operations Manager and the Clinical Nursing Supervisor, the scan for pressure injuries and their subsequent staging may not be happening consistently with every patient. Nevertheless, there is a prescribed process for assessment and documentation for the nurses to follow. The diagram below, labeled Figure 1, details the prescribed process.Figure 1: Prescribed process for pressure injury assessment and documentationThis process applies to the initial assessment after a patient is admitted, the daily assessments to occur, and the assessment at discharge. The documentation from both the nurses and physicians is used by Operations. It should be noted however, the status determined by the physician is final for Operations’ purposes. Still, if the Operations Department encounters an inconsistency in the documentation or inconsistency between documentation from various times during a patient’s stay (i.e. a pressure injury is documented at admission but then there is no mention of a pressure injury at any other time) they are forced to query the physician to verify the information before they are able to move forward. In summary, through collaboration with the coordinators and client, we identified the following key problems for this project:A low level of compliance with the current prescribed processInconsistency of pressure injury assessmentInconsistency between nurse and physician pressure injury documentationInconsistency between pressure injury documentation at different times in a patient’s stayToo much time spent verifying pressure injury documentation relating to pressure injuries for coding/Operations purposesPoor communication between nurses and physicians regarding pressure injury statusThroughout the project, the team was able to investigate all of the above problems and this report details the steps the team took to collect and analyze data as well as provide recommendations for solutions to those problems.GOALS AND OBJECTIVESThe overarching goal of this project was to recommend an optimal process for pressure injury assessment and documentation, which would reduce the number of documentation inconsistencies and improve communication between nurses and physicians relating to the assessment and documentation of pressure injuries.In order to meet this goal, we defined the following key objectives:Simplify the assessment and documentation processIncrease nurse and physician compliance with assessment and documentation processImprove nurse-physician communicationStreamline nurse and physician workflowMake process implementation as simple as possibleReduce extra work required to verify inconsistent pressure injury documentationImprove patient careDespite the COVID-19 outbreak, our key objectives remained the same. However, the team, client, and coordinators all agreed expectations for the final recommendations would have to be adjusted -- more of this is explained in the Deliverables sub-section of the Design Process.PROJECT SCOPEThe project scope included pressure injury assessment and documentation by nurses and physicians at all times of a patient’s stay within the Michigan Medicine Inpatient Rehab Facility. It also included nurse-physician communication relating to pressure injuries. Another consideration within scope was the way pressure injury documentation is used within the Operations Department and how pressure injury documentation affects the reports required by the Center for Medicare and Medicaid Services and for the Quality Reporting Program. Tasks not connected to the pressure injury documentation process were not included in the scope of this project. Other tasks or requirements related to the Patient Assessment Instrument (PAI) completed by Operations and/or the Operations Department were not studied. During the course of this project, we did not use data from other departments related to pressure injuries. The findings and recommendations from this investigation could be used in the future for similar processes in other Michigan Medicine departments.As with the objectives, there were no changes to the scope as a result of COVID-19, but again, the entire project team understood there might be limitations as to what could be ultimately accomplished in the project, within the project scope.DESIGN PROCESSEngineering Challenges The nature of this project required the team to focus on process improvement. The team considered the Theory of Constraints when conducting observations and analyzing our findings. This helped us identify the most important limiting factors preventing the documentation system from being improved as a whole. Then, we were able to use the constraint theory to systematically improve the constraints until they were no longer the limiting factors. Literature SearchAfter thorough research regarding pressure injuries and corresponding documentation, we found various articles to aid the team in deducing which methods to use for data collection. In addition, the articles provided insight on how other institutions approach thorough, informed, and consistent documentation of pressure injuries. It is estimated pressure injuries account for $11 billion yearly [3] and can be a great financial burden to healthcare institutions if documented incorrectly by Billing. Research shows a common theme showing the quality of documentation increases when there is a standardized process in place as stated in reference [2]. The new standardized process utilized there included new documentation templates, new documentation criteria, and a closer review and auditing of all documentation. As a result, our team chose to focus on finding ways to alter the current prescribed process for pressure injuries in the MMIRF in order to produce fewer inconsistencies. This study was a great reference point for this project. We also looked at a past IOE 481 report from 2006 which analyzed the University of Michigan’s nursing documentation process. They found generally, nurses with more experience spend more time documenting than nurses with less than one year on the job [1]. This was an interesting concept we considered investigating but ultimately chose not to as we narrowed down our project scope. Nevertheless, it is something to potentially investigate in the future.Design ConstraintsOne constraint we had to consider for this project is MMIRF uses flowsheets in MiChart to document pressure injuries. To ensure pressure injury documentation remained easily accessible to all hospital personnel, our new documentation process had to utilize flowsheets in MiChart. In other words, we were not able to create an entirely new place for documentation of pressure injuries or make excessive changes to the flowsheets rendering them confusing to other hospital entities. Another constraint relating to the assessment process we designed was we could not change the way the nurses and physicians stage the pressure injuries (they currently use the National Pressure Ulcer Advisory Panel’s (NPUAP) Staging System). Essentially, we could make changes to other aspects of the assessment process but we would not be able to create a new system for staging. Finally, as a result of COVID-19, another constraint was placed on our project - we were unable to continue observations in the MMIRF as of March 14, 2020. As a result, we were unable to complete the number of observations we had originally planned, and we were unable to conduct any physician observations. In addition, COVID-19 greatly increased the workload of all who work in University Hospital (including those who work in the MMIRF), so we had to adjust our interview plans and cancel surveys in order to better accommodate everyone’s busy schedules.Design StandardsThe team followed all Health Insurance Portability and Accountability Act (HIPAA) standards including the guidelines to protect patient information. In addition, the team worked withthe client and continuous improvement coordinators to ensure all health and safety standards mentioned in the University of Michigan Facilities and Operations Codes and Regulatory Agencies List were met. Finally, we followed the standards set in the National Pressure Ulcer Advisory Panel’s (NPUAP) Staging System. A summary of the Constraints and Standards can be found below, in Table 1.Table 1: Constraints and standards matrix OrganizationalEthicalHealth & SafetyConstraints Documentation Must Remain in MiChart Flowsheets x Staging Cannot Be Changed (Must Follow NPUAP Staging System) x xStandards HIPAA xx U of M Facilities & Operations Codes & Regulatory Agencies List xxxNPUAP Staging System xx Design RequirementsSome requirements we considered for our project are listed below:Design a collaborative, standardized process for nurses and physicians to assess and document pressure injuries Facilitate easy and efficient documentationMaximize the communication between nurses and physicians who are located in different areas of the hospital and maybe visiting patients at different timesEliminate any pain points from the assessment and documentation processMake the documentation process as clear as possible and create a “universal language” relating to pressure injuries between various entities of the hospitalPugh MatrixSee the Pugh matrix below, labeled Table 2, which we used to rank alternative solutions using the above design requirements. Note the Pugh matrix is empty -- later in the report, in Appendix E, there is a completed Pugh matrix showing the score of each solution we are presenting. The current state baseline is a score of 0, and each alternative receives a score of +1 or -1 for each criterion, based on whether the alternative is better (+1) or worse (-1). Then, the criteria score for each alternative are added up to give the total score.Table 2: Pugh matrix template for this projectCurrent StateAlternative 1Alternative 2Etc...CriteriaImprove Teamwork and Collaboration0Simplification of Process0Reduce work to verify discrepancies0Improved Patient Care0Ease of implementation 0Total0DeliverablesThere are three main deliverables our recommendations provide to the client:A newly designed collaborative process for nurse-physician assessment of pressure injury status on admission, throughout the stay, and at dischargeAn improved method of pressure injury documentation that is accurate, timely, and consistent between nurses and physiciansA key metric for measuring successful implementation and future performance of the pressure injury assessment and documentation processDATA COLLECTION AND ANALYSIS METHODS Over the course of this project, the team collected and analyzed historical data, conducted observations with nurses, physicians, and the Operations Department, and interviewed Nursing, Physician, and Operations leadership.Historical Data The team was given historical data from the Operations Department concerning the number of queries for pressure injuries from Operations to physicians for July 2019 - January 2020. Operations query the physician when there is an inconsistency found between/within nurse and physician pressure injury documentation. Therefore, we used data regarding the number of queries made to define the current state of the problem with pressure injury documentation inconsistencies.Observations The student team observed the nursing staff and the Operations Department. We conducted about 6-7 hours of nursing observations in the MMIRF and 1 hour of Operations observations (via BlueJeans since the Operations Department works remotely). During the nursing observations, we observed pressure injury assessment at patient admission as well as daily assessments, as well as how pressure injuries were then documented in MiChart. We also observed the handoff from nurses to physicians regarding pressure injuries. During our observation of the Operations Department, we observed the CMS Prospective Payment System Workflow for the 6A Clinical Info Analyst when completing the IRF-PAI. The team observed how Operations and Operations use the documentation from nurses and physicians, as well as the process for addressing inconsistencies found between/within nurse and physician documentation of pressure injuries. For all observations, the team took detailed notes during and immediately after observation. Some examples of notes for a nursing observation would be writing down the steps the nurse took to assess a pressure injury, noting where and how the nurse documented the pressure injury, and answers to any questions we asked during the observation period. For the Operations observations, we took notes detailing the steps of the process of querying pressure injury inconsistencies, answers to questions we asked, etc.InterviewsTo make sure the team addressed concerns and meet the needs of the client, interviews of stakeholders and people in authoritative positions were held. The people interviewed were Andrea Harris (Operations Manager), Dr. Edward Claflin (Medical Director of the MMIRF - replacement for Dr. John Danko who went on personal leave), Kelly Gawne (Nursing Director), Nicole Stiltner (Nurse Supervisor), and Paula Anton (Clinical Nurse Specialist). Interviews consisted of phone conversations, virtual meetings, and email exchanges. We asked these individuals to describe the current process as well as any shortfalls they had noticed, how they thought the process might be improved, etc. These interviews really provided insight into how the leadership of the various teams felt about the current state of the process. The team was able to further develop the wants and needs of the project, as well as discuss potential solutions to confirm the feasibility and get support from the various entities who would be involved with each.FINDINGSThe team met, discussed, and synthesized all observation notes and interviews to look for general trends in the pressure injury assessment and documentation process. Our findings from our analyses are detailed in the following section.Historical DataFrom July 2019 to January 2020, 48% of pressure injuries recorded required an inquiry. Therefore, since queries are made when an inconsistency is found between or within nurse/physician documentation, we can say 48% of pressure injury documentation showed inconsistencies. In other words, the Yield for this process was 52%.Nurse ObservationsNursing observations revealed many nurses were unaware of the Billing and Operations department’s requirement for physician documentation. The skin checks were being done very consistently and thoroughly throughout patients’ stays, and there were no issues with the capability or knowledge of staging. However, we noted after skin checks were executed, various nurses would note pressure injuries using unique language, varying amounts of information, and/or in various locations. We were also able to gather the nurses' feelings as the current process is not very organized or efficient. Operations ObservationsFrom observing Operations, we focused on what aspects of pressure injuries are important for the completion of the IRF-PAI purposes. We were able to gain insight into how inconsistencies were revealed in the documentation and the process of getting clarity. The process usually begins when Operations is filling out the PAI and notices there is incomplete or missing information whether it be the physician sign-off or timeline holes about the pressure injury in question. From there, the analyst must inquire further by looking through MiChart notes and contacting the relevant physicians to confirm or clarify the patient notes to ensure accuracy in Operations documentation. This process of contacting and hearing back from medical staff could take several hours. InterviewsThe interviews were informal and integrated into the client check-in calls. Interview format changed to sending questions and getting written answers back through email as COVID-19 took priority for medical staff. A set of questions submitted to the Nursing leaders can be found in Appendix A. Unfortunately, due to the medical staff’s current reality and workload we were not able to get specific answers for all questions. In the beginning, interviews were asking questions to gain an understanding of the stakeholders’ concerns and processes. The information from these interviews formulated the project's background information and key issues. Towards the end of the project, it served the purpose of asking about logistics and checks and balances surrounding feasibility as we were formulating our recommendations. The team found early on the different parties were not aware of some of the issues and concerns from other departments surrounding pressure injury assessment and documentation. All leadership agreed there was room for improvement in the existing processes and the communication occurring between parties was inadequate. CONCLUSIONSThe team discussed our findings from our analyses and the conclusions reached are detailed in the following sections.Historical DataThe historical data clearly showed there was a significant problem with the current pressure injury assessment and documentation process, and inconsistencies in the documentation are indeed common, as suspected by the client. After all, a 52% Yield is quite low. Furthermore, each documentation inconsistency found required workers in Operations to complete extra work (which could even be considered rework). These queries take time away from the rest of their work, in addition to disrupting the work of nurses and physicians. Finally, inconsistencies and potential inaccuracies in pressure injury documentation also affect the pressure injury data publicly reported by the MMIRF, which could impact its overall reputation.Nurse ObservationsFrom observations, we found wound checks were being done consistently upon admission and routinely throughout the patient’s stay. The issues we saw were surrounding documentation style in MiChart. After skin checks, nurses are responsible for noting the skin check did occur, who assisted with the check and the results of it. From observations, we noticed skin checks were being completed but if the nurses did not find a pressure injury, noting this would be overlooked as there is no designated spot for pressure injuries in the general plan notes only in the Wounds section of the flowsheets. Also, after nurses perform their skin checks, physicians have the task of confirming their assessment. We saw there was little to no communication between the nurses and physicians as to confirming these wounds. Physicians are to look at the nursing notes but sometimes this does not happen so disconnects in this process occur often. Ultimately, there seems to be no clear, standardized process for assessment and documentation. Thus, there is a lack of collaboration between the nurses and physicians which causes confusion and allows room for disconnect about pressure injury information in the documentation. Operations ObservationsWe were also able to shadow the Operations department and saw how the inconsistencies in documentation trickled down into Operations’ workload. When these inconsistencies are found, it takes time and effort to get clarity about pressure injuries including were there any pressure injuries, what is the status of the pressure injuries, and have the physicians confirmed and signed off on those notes. From this shadowing, we found the root causes of confusion and inconsistencies begin with patient care processes, specifically patient notes. Notes about skin checks were found in many different places or notes about skin checks would fall off throughout the patient stay. If skin checks were not documented, it is as if they did not exist. When Operations looks for these notes and if there is nothing documented, they have to confirm there were no pressure injuries. This entire process causes time delays and extra work for everyone involved. InterviewsThe team determined the first step for efficiency was to get everyone on the same page regarding requirements and the needs of each department involved in the processes. Ensuring everyone is aware of how their portion of the process affects the next is extremely important. Also, facilitating better communication, indirect or direct, is key to aiding the issues presented in this project as well as others. Following the Nursing leaders’ final interview, the team concluded that there was not a need to re-train the nurses but additional training could be beneficial for the doctors and it would be more feasible since they are a smaller group. Also, the Wound Specialist currently is the main person that places pictures into the flowsheets. If inputting pictures becomes a requirement the specialist cannot be responsible for the completion of this for all patients, therefore, requiring the unit to need more of the appropriate devices.It was requested of the team to provide recommendations regarding the additional data needs from this project and for potential future IOE 481 projects. RECOMMENDATIONSDue to the current international health crisis, the team was required to make adjustments in every aspect of the project which affected our recommendations. All hospital observations ceased along with in-person interactions to adhere to government orders. The team was not able to develop a “newly designed collaborative process for nurse-physician assessment of pressure injury status” as there was not enough data or time to test and confidently recommend one. Using our completed findings and conclusions, we developed the following potential solutions for the MMIRF. These solutions are changes or additions to help alleviate the problems found by ensuring all parties share an understanding of how to stage and how to document. As well as facilitate better communication between those involved with pressure injury assessment and documentation in MMIRF. The Pugh matrix for these solutions is in Appendix E. Standardized Template in MiChart for Pressure Injury DocumentationAfter completing observations with the nurses, it was apparent pressure injuries (PI) were not documented the same by each nurse within the notes. The implementation of this method would add a detailed section to the already existing template the nurses use. This portion of the template will address the following questions: Does a PI exist, Did it exist prior to admission in MMIRF and what stage is the PI. This method addresses the variations in where information is documented and the language of the documentation. A sample standardized template for the pressure injury add-on to nursing notes in MiChart can be found below. Pressure Injury Assessment GuideNurses will be provided with either a tangible pocket card containing pictures of examples of the stages or it can be added to the “Wounds” section of the patient charts. The visual could consist of definitions, figures, or both based on the standards of the National Pressure Ulcer Advisory Panel[4]. Using a staging guide has the potential to improve assessment, identification, and documentation of pressure ulcers [5]. This method would resolve the inconsistencies in pressure injury assessment and variation of language in the documentation. Appendices C and D provide the team’s pocket card and assessment guide, respectively. Include Figure of Pressure Injuries with Physician Sign Off Upon identifying a pressure injury, the nurse (or physician) should take a photo to be a visual aid in the flowsheets. This can be implemented for all stages of pressure injuries or those identified as Stage 2 and above. Including the photo will allow the doctors and nurses to be on the same page even if the other party has not yet seen the pressure injury. Also, photo documentation will make tracking the progression of a pressure injury more efficient. If the physician agrees and confirms the nurses notes then they should sign off on the notes indicating all parties are in agreement.Use Queries to Physicians as a Key Performance IndicatorWhen the Clinical Info Analyst identifies inconsistencies during the PPS workflow process they cannot logically rectify a query is sent by email to the patient’s attending physician. The team recommends the number of queries per month to be used as the key metric for measuring successful implementation and future performance of the pressure injury assessment and documentation process. The queries will need to be manually tracked in a secure spreadsheet. Minor inconsistencies are considered things she noticed but did not have to send a query because she was able to logically resolve the issue. Major inconsistencies are considered instances when an email query needs to be sent. In order to ensure instances can be differentiated the team recommends the records include the following: Is the inconsistency noted upon Admission or Discharge? What type of issue is it?location discrepancy size discrepancystage discrepancytime acquisition of wound discrepancylanguage inconsistency (i.e. description of wound bed color or characteristics, etc.)Usage of this key metric may require comparison with historical data from the Operations Department to have a base level. The use of Operations query data from within MiChart is hard to extract but it would create a more robust data set and provide a multi-layer review process to produce more accurate data.Per Nursing’s RequestThe team included training for pressure injury staging in the original alternatives considered. We believe the nurses are well versed in this material but it may be beneficial for the IRF attending physicians to receive additional training. Since this is a smaller group it would be a more feasible recommendation. This could be a portion of a future project for IOE 481. Also, during our nursing observations, it was expressed the admissions process is inefficient but due to the scope of our project, we did not have the time to look into their concerns. The admission process can be time-consuming during peak hours in the unit. Both of the above concerns could act as a continuation of this current project. EXPECTED IMPACTOverall, we expect these recommendations for changes/additions to the pressure injury assessment and documentation process to lead to:A reduced number of inconsistencies in pressure injury documentationFewer queries from the Operations Department to verify various inconsistencies in documentationIncreased accuracy of pressure injury documentation on admission, throughout stay, and at discharge Increased timeliness of pressure injury documentation during a patient's time in MMIRFIncreased compliance with pressure injury assessment and documentation processREFERENCES [1] Atiset, O., Aziz, N., Shiyin, H., Perry, C. (2006). University of Michigan Health System Program and Operations Analysis. Analysis of Nursing Documentation Process[2] Boyko, T. V., Longaker, M. T., & Yang, G. P. (2018). Review of the Current Management of Pressure Ulcers. Advances in wound care, 7(2), 57–67. [3] Dahlstrom, M., Best, T., Baker, C., Doeing, D., Davis, A., Doty, J., & Arora, V. M. (2011). Improving identification and documentation of pressure ulcers at an urban academic hospital. Joint Commission journal on quality and patient safety, 37(3), 123–130. [4] Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. Journal of wound, ostomy, and continence nursing: official publication of The Wound, Ostomy and Continence Nurses Society, 43(6), 585–597.[5] Ruggiero, Cynthia. (2015). "Pressure Ulcer Assessment and Documentation". Master's Theses, Dissertations, Graduate Research, and Major Papers Overview. 127.APPENDIX A: SET OF INTERVIEW QUESTIONS Could you provide a blank screenshot of what the General Plan of Care notes nursing template looks like?Could you provide a screenshot of the ‘Wounds’ section of the MiChart flowsheet used? (Could be blank or a mock patient)Is it possible to adjust the general plan of care notes template that the nurses use? Who is in charge of creating/designing the template?Do you feel a physical staging visual is beneficial and feasible (regarding use by nurses)?Do you all have guidelines for documenting? (i.e. the wording, what should be covered, etc.)It was mentioned to us that audits occur on nurse documentation regarding Pressure Ulcer/Injuries. Could you describe what this looks like and what you all are looking for?Is it true that Physicians can sign off on Nursing notes? Is there a place designated for this?Are the nurses aware of the process that occurs in Operations and Billing in regard to the IRF-PAI?APPENDIX B: SAMPLE STANDARDIZED TEMPLATE FOR MICHARTAPPENDIX C: SAMPLE POCKET CARD APPENDIX D: PRESSURE INJURY ASSESSMENT GUIDEAPPENDIX E: RECOMMENDATION PUGH MATRIXCurrent StateStandardize Note TemplateAssessment GuideInclude Figure and Physician Sign-offCriteriaImprove Teamwork and Collaboration0+1+10Simplification of Process0+10-1Reduce work to verify discrepancies0+1+1+1Improved Patient Care0+1+1+1Ease of implementation 0+1+1-1Total0540 ................
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