Organizing Clinical Information Systems to Manage and Improve Care

Our Documentation System
1994 to 1996

Unresolved Problems Included:

“Fix” the System or De-install!

Goals of Re-design

Review of Literature

No current methodologies supported our vision:

Patient Centered Documentation

The foundation of documentation is based on our Standards of Care

Standards of Practice

Intervention Development

Bundled Intervention:
(Statement of expected care)

Patient Centered Documentation
(Keep Bundled Interventions Honest)

Patient Centered Documentation

Problems are triggered based on
identified needs (Assessments)

Individualized Plan of Care

Dictionaries dedicated to no duplication/ ambiguity

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Documentation Time
Pilot Study 1997 (One Hospital)

Incremental Overtime

Nurse Satisfaction

Based on this success, Administration took ownership

Ground Rules

Developing Clinical Documentation

Iterative Process

Organizational Structure

Clinical Information System Accountability Structure

2nd Generation Accountability
(Stabilized System)

Summary of Success Factors

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Rose Medical Center
Observational Study

Rose Medical Center
Satisfaction Data

Rose Medical Center
Evaluation of Goals

Patient Centered Documentation

Case Studies in
Strategic Problem Solving

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Can my hospital do this?
YES!

What have we learned
and
What does it mean?

Meditech, as a vehicle, CAN
get us where we want to go

As a group, we all have
enormous opportunity

We all want the same thing:
An efficient information system

ESTALISH YOUR OWN WORTH!
If  you are in the process of any type of change:

COLLECT AND PRESENT
DATA

* Illustrate and produce results
    to your CNO/ CFO

*  Process Improvement presentations                       

*  Publish Your Results

Demonstration of  our
value will help us get the
assistance we need.

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