I recently encountered an episode of unexpected user
behavior. I was visiting one of the specialty departments that use a third
party software to capture, record, and document procedures. This application has
both an inbound ADT and outbound report interface with the primary hospital
information system. I arrived in the
department to observe and discuss an upcoming conversion activity to upgrade
the department’s software. The vendor had
notified us that they would be discontinuing software support of the current
version. We were given six months to complete the software conversion to their
newer product before the support ended. This
department has a small group of users, less than 20. I wanted to observe and
validate their current workflow.
It has been my experience that workflows change over time and
that changes are related to a number of influences and with good reason. As I began to talk with the nursing staff
about the upcoming software update, I reiterated to them that the success of
the implementation of the software update relied on my full and accurate understanding
of their current workflow. I let them
know that I assumed workflow changed had happened with this group of users. I was here to document the current workflow, including
their work processes (e.g., types of tasks, user behaviors) and desired
outcomes. I let them know that as partners an optimal work solution could be
designed. My objective was to give them tools to improve the quality of care
delivery.
The first activity I observed was “patient intake.” According to the previously recorded
workflow, the staff members would select a patient name from a list of outpatients
(sent via an ADT interface) that had been pre-registered for their unit
location. The staff members were to
verify the patient name, unit number, and DOB and then select the correct
patient from the list. What I witnessed
was the staff manually entering in a patient name, DOB, unit number, date of
service, and account number of all the scheduled procedure patients for that
day. Upon investigation, I discovered
that 3 months prior to my visit, the ADT interface had stopped working. Because the staff knew there was a way to
manually enter a case, they adopted a workflow change in order to continue
their process of seeing and treating patients.
Nurses are very resourceful and committed to achieving their mission of
care delivery. When the ADT interface stopped working, in the heat of the
moment, the staff worked to find a quick solution to complete their mission:
providing care for the patients.
Notifying IT services wasn’t a priority and was something they could do
later. Somehow later never came and the notification never happened. What I viewed
as a simple and straightforward task, i.e., call and notify the IT helpdesk, was
viewed by the staff as less or not important.
Of course, the current user behavior I observed, although
well intended, was a potential safety problem. The new workflow circumvented
processes designed to support positive patient identification. My priority now would
be to restore the functioning ADT, so that data entry errors could be mitigated
and positive patient identification could be supported. I suspect also that the 20 minutes the staff had
been spending each morning building the patient list would now be available to
them for reinvesting in other work.
Prudent practices help
prevent and/or detect problems caused by duplicate records, patient mix-ups,
and “comingled” (or “overlay”) records. Health IT can help mitigate issues
associated with patient mis-identification by making sure that clinicians are
able to select patient records from electronically generated lists based on
specific criteria (e.g., user, location, time, service). Misidentifying
patients is a known issue within healthcare delivery and creates a number of care
issues to include:
a.
incomplete medical information to support
clinical decision-making,
b.
incorrect patient information integrated into
someone else’s (i.e. comingling) record the corrupts clinical decision-making,
c.
failure to notify a patient of a procedure
result/outcome that may delay treatments/therapies, and/or
d.
notifying a patient of a medical condition that
is false, creating undue stress and anxiety.
This adventure taught me several
things and, as a result, some of these lessons I will save for a future blog. For today’s blog I will address “no reporting”
and how to support issue discovery. After all, if users/staff don’t report, corrections
will not happen, and well-intended workarounds will persist with the potential
for patient harm lurking/waiting.
Once again, I am reminded of a Patricia Benner’s nursing
theory construct of nurse presence. Benner writes about the benefits gained by all
parties by nurses simply being present with the patient/family. Her construct extrapolates to me and the
users I support. . My presence with
nurse users will influence – hopefully in a positive way -- their perception
and experience. In this journey of mine as an INS, I am in relentless pursuit
of making people better at what they do.
Lesson Learned: Don’t assume staff will report software
issues and don’t assume silence is golden.
The value of being present is so important.
This experience got
me thinking back to the days when I was a manager. One behavior I had adopted as
a manager was rounding on my staff daily to “check in” with them. I had specific questions I would ask them and
I would record the replies and use my notes as a follow up tool to address staff
concerns. I decided it was time to apply a similar technique to my INS role. I developed a tool to provide a meaningful
“rounding” of Health IT users. This
tool, a spread sheet that I could carry with me, focuses my questions to users
and allows me to record the issues that were raised. Currently, my question set is as follows:
1.
What in the system is
working well for you today?
2.
Are there any system
issues that you have identified that negatively impact quality or safety of
care delivery?
3.
Is there one thing
that the system does well for you in supporting the delivery of care that you
hope never goes away?
4.
Do you have any
concerns or suggestions for improvement that you would like to tell me about
today?
I began to “round” with my users, collected responses, and
looked for themes. The more frequently a topic appeared, the more I looked into
it. Occasionally, the staff would
mention something that was not really related to Health IT. Quite familiar with
the hospital departments, I passed this feedback on to the appropriate
individual. My “rounding” activity has not and will not replace other reporting
methods. I am using it as a supplemental
tool to keep me in touch with those unpredictable behaviors that users sometime
demonstrate because … users do unexpected things
