More than IT

While standardization and automation of processes is a proven path to enhanced patient care and safety, achieving these goals across disparate environments can be a daunting task. The differences between cultures and facilities can defeat the best-laid plans and the most effective software solutions. Technology alone is not enough—success requires the effective combination of technology, people and process change.

Serving the greater Cincinnati area, my organization, Mercy Health Partners, is a not-for-profit, integrated delivery network that includes five community hospitals with over 1,000 beds.

Three years ago, we embarked on a multi-faceted program designed to achieve significant patient safety improvements through system-wide standardization of clinical processes. Early on, our management team recognized that it would take more than technology—preparing each organization for change and redesigning clinical workflow would be just as critical. Our key to success centered on building one system that could then be deployed effectively across multiple environments.

We had long recognized the benefits, cost savings and patient safety improvements that could be achieved through standardizing and automating care and the medication-use processes with technology. We also knew that any implementation could face significant obstacles. While evaluating organizational readiness at the five hospitals, we found five different cultures and a myriad of care processes.

Mercy Health faced a tremendous challenge. Standardization was high on our list in order to decrease variations in clinical practice, enhance data comparison and improve safety. But our assessment revealed that each hospital had very different medication-use processes. While we knew that technology could help standardize processes, we also understood the impact of system implementations on clinicians and their care delivery practices. We needed clinical expertise to produce a successful transition.

We selected San Francisco-based McKesson Provider Technologies to support our patient safety initiative with solutions and services that would prevent medication errors at each stage where they could occur—prescribing, transcribing, dispensing, administering and monitoring. These solutions included the deployment of a pharmacy information system across the enterprise in conjunction with an on-site bar code packaging service and medication administration system. Once those solutions were in place, systems for nurse documentation, clinical alerts and provider order entry/clinical decision support rounded out the safety suite.

However, before we moved forward with the technology implementations, we developed a plan to transform clinical practice, bring about IT adoption, and keep the clinical system implementations on track.

IT and automation are important tools to implement best practices and standardize care delivery, but process evaluation and redesign are the critical first steps. It was important to develop a bridge for linking each facility and bringing about the needed standardization.

Through this process, we identified areas requiring improvement using an in-depth study that included 249 chart audits of more than 17,800 administered medications coupled with interviews, observations, and policy and procedure reviews. We discovered inefficient workflows, and that 33 percent of prescribed medication orders and 11 percent of transcribed new orders did not meet standards set by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

Adopting a philosophy of "build as one, deploy as many," we engaged the key stakeholders in a concerted program to gain buy-in. Mercy's multi-disciplinary team worked with consultants from McKesson to develop five strategic goals. These included:

1. Enhance patient safety by reducing the frequency and severity of medication errors and near-errors.

2. Implement technology to facilitate validating the "five rights" of medication administration.

3. Streamline communication between pharmacy and clinicians regarding patient medication.

4. Redesign medication practices and policies to maximize patient safety.

5. Standardize medication dispensing and administration processes and policies across facilities.

To enhance safety and support nurses managing multiple medication schedules, we developed standardized processes for IV administration times and frequency. Finally, because some Mercy facilities used nursing servers while others accessed centralized charting, we decided to complete all patient charting electronically and eliminate error-prone paper charts. Computers on wheels (COWs) were deployed to nurses, giving them a mobile workstation and centralized source of patient information.

Developing greater understanding among patients was also a vital part of this process. A one-page handout explaining the new system and the benefits for patient care and safety was given to each patient.

We've been very pleased with our results to date. Postdeployment studies revealed a bar code scan rate for all administered medications of 96-98 percent. Variance reports are accessed on-demand providing data on individual rates of scanning by personnel. This information provides managers the opportunity to engage nursing staff in training and encouragement to boost usage.

A key to our success also lay in empowering nursing leadership to protect the project's super users. These key personnel must not be pulled back into staffing too quickly simply as means of raising census. To do so prolongs reaching usage or adoption goals and often promotes greater anxiety among system users. These misgiving and frustrations can quickly be transferred to physicians and patients in the form of negative statements and potentially delay the success of the project.

Our goal was to make the computer a clinical tool to enhance patient care. Like the stethoscope, while not a replacement for the nurse's caring touch, it is an added asset to the caregivers experience and critical thinking. At Mercy, the technology tools also became a means for transforming and enhancing care delivery.

Since the deployment of the nursing documentation and medication scanning technology on the COWs, we have found that nurses are spending an increasing amount of time in and near patient rooms rather than at the nurse's station. Physicians in particular have noted that while rounding, they see nurses spending more time closer to patients' rooms—even during off-shift and off-med periods.

With standardized and accelerated implementation of these patient safety technologies across the enterprise, Mercy has realized significant results. The consulting team's medication safety assessment identified 189 opportunities for improvement and prioritized five process areas: medication reconciliation process, medication administration record (MAR) at bedside, MAR reconciliation, tall man lettering of "sound alike/look alike" formulary medications and 24-hour pharmacist order review across all facilities. A total of 82 improvements were implemented to reduce potential transcription and medication errors.

The high level of buy-in among staff can be seen in system adoption rates. Between 96-98 percent of all medication bar codes are scanned before administration to verify the "five rights." The real-time electronic documentation of medication administration has also enhanced access to vital patient information and communication among nurses, pharmacists and physicians. We saw a significant decrease in the number of phone calls needed to clarify medication orders between nursing and pharmacy staff.

In addition to reducing our pharmacy formulary from 6,000 items to 2,500, Mercy significantly reduced system build and test times. The consulting engagement resulted in a resource cost avoidance of 1,320 hours for installation of the pharmacy system. In total, Mercy reduced resource hours spent by almost 14,000, resulting in a 5.8 return on investment from the clinical consulting engagement.

Our strategic imperative is to be the preferred healthcare provider in the communities we serve. Through the strategic use of clinical consulting expertise, we were able to pinpoint objectives and direct our efforts toward proven methods. The process from build to implementation became seamless and reduced our deployment timeline. In addition, by transforming five disparate hospitals into a single integrated system, we have standardized care and medication-use processes across the organization. Most important, we have achieved new levels of patient care and a much safer medication-use process.

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