August 27, 2019
By Steve Bryant, President and Chief Executive Officer, The Greeley Company
Steve Bryant, president and chief executive officer of The Greeley Company, discusses why complex documentation workflows lead to missing and inaccurate entries and provides steps that organizations can take to begin the journey back to simplicity.
It’s ironic. The primary reason for today's overwhelming and overly-complicated hospital policies and documentation systems is the quest for compliance and safety. Yet the only way to actually achieve sustained compliance and safety is to streamline policies and documentation workflows. Unnecessarily complex policies are not followed. Complex documentation workflows lead to missing and inaccurate entries. Regulatory, liability, and patient safety risks are vastly increased and caregivers burn out.
How we got here
Survey Response and Readiness: An accreditation survey team comes to your hospital and identifies 32 things to fix within 60 days. The state licensing agency also makes frequent visits to investigate complaints and self-reported adverse events resulting in more things to be corrected, this time in 30 days. Responding to this cascade of citations inevitably leads to a string of quick fixes and band aids.
Less than pleased with the number of regulatory and accreditation findings, the CEO asks the hospital’s Survey Coordinator to identify all possible vulnerabilities before the next agency visit. The Survey Coordinator organizes internal “tracers” and commissions mock surveys to identify as many vulnerabilities as possible. Most of the issues identified during these tracers and mock surveys are "one-off" findings—imperfections in an otherwise credible system–-or are based on regulatory myth rather than an actual requirement. Only a few tracer/mock survey findings touch on significant systems flaws that put the hospital in regulatory peril or present a significant safety risk to patients.
Root Cause Analysis: Something bad happens and a team works feverishly to find the root cause. After weeks of meetings, the team fails to find a root cause within its span of control but, rather than do nothing, it focuses on several minor flaws with little relationship to the error under analysis. These flaws are addressed by adding steps to a procedure or more check boxes and hard stops to the electronic record.
Structured Data. Hospitals are told that narrative, non-structured entries in an electronic health record signal a failure in design. Although it is true that 10-15% of entries in the inpatient electronic record are worthy of aggregation, attempting to “structure” clinician communication—creating click boxes or drop-down menus for data that will never and should never be aggregated—leads to incredibly complex documentation workflows that fail to communicate. They also contribute to significant data inaccuracies as care givers “blow past” a string of check boxes just to get through all of the hard stops and finish their documentation.
Rather than ignoring unnecessary complexity, many organizations choose to begin the journey back to simplicity by taking the following first steps.
Step 1: Guidelines
Real-life clinical processes branch radically. Example: anyone presenting to the emergency department should be triaged — unless the individual is being resuscitated, or there is no wait for a physician, or the individual is just asking for directions, or (fill in the blanks). Accounting for all the “what ifs” in a clinical process can easily grow a procedure from one sentence to many pages.
Such procedural overkill can be avoided by adopting the concept of a guideline: the usual way things are done, with exceptions allowed for justifiable clinical or operational considerations. The concept of guidelines for selected clinical processes is consistent with the principle of just culture and avoids procedure bloat since the author does not have to account for every possible clinical contingency.
Step 2: Abandon Regulatory Myths
Some of the most burdensome (and unnecessary) policies and documentation workflows stem from regulatory myths such as, “restraint must be re-ordered every 24 hours,” "cardboard boxes are not allowed in hospitals," and “nurses must document a separate care plan.” It is important to study the actual requirement before complicating policy requirements or elements of documentation based on a surveyor comment, an invalid or misunderstood regulatory citation, or custom.
Step 3: Moving Forward
There are many steps to simplifying policies and documentation workflows, more than we can cover here: steps like taking control of survey results, redesigning the survey readiness function, streamlining the care monitoring process and other approaches. Yes, making things simple is not easy, but it is essential if a hospital hopes to sustain compliance while implementing efficient, highly reliable processes.
Steve Bryant, President and Chief Executive Officer, The Greeley Company, brings more than 25 years of experience in healthcare management and leadership to his work with hospitals, physicians, and healthcare organizations across the country. In his current and prior leadership roles with Greeley, Mr. Bryant has played an instrumental role in driving the company's mission to help healthcare organizations solve complex challenges, improve efficiency, comply with regulations and standards, achieve practitioner engagement and alignment, and excel in delivering high-quality, cost-effective patient care.