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The Future for Nursing Documentation in High-Reliability
Systems
Jettie Eddleman, BSN, RN
The Future for Nursing Documentation in High-Reliability Systems
the right care
at the right time,
every time
What is drivinghealth care systems change?
• Etiology of medical errors• Breakthrough technologies • Regulations and Policy
To Err is Human- IOM 1999• Life or death documentation• Medical errors and their consequence• Just Culture and systems thinking• Culture of Safety• Patient Safety Act of 2005
Comprehensive Addiction and Recovery Act (CARA) 2016
• This act authorized many harm-reduction strategies, including increased access to the overdose reversal drug naloxone, for the opioid crisis, but didn't provide any federal funding for implementation
• The Cures Act designated 1 billion over 2 years to fight the opioid epidemic
• Example of systems with standardized treatment and documentation
21st Century Cures Act 2016• Cures Act: 3 Section 4003 of the Cures Act
provides that interoperability includes: • enables secure exchange and use of electronic
health information without special effort on the part of the user;
• allows for complete access, exchange, and use of all electronically accessible health information for authorized use;
• defines and set fines for information blocking.• 6.3 Billion in funding, mostly for NIH
2018 TEFCA• Trusted Exchange Framework and Common
Agreement (TEFCA)• On-ramp for Health Information Exchange
(HIE) to enable providers, hospitals and other healthcare stakeholders to join any health information network (HIN) and then to automatically connect and participate in nationwide health information exchange.
Interoperability The 21st Century Cures Act 2016–defined interoperability –prohibited information blocking–$1 million per blocking violation
Information Blocking
• Information blocking is defined as a practice that interferes with or prevents access to electronic health information, that is, information about a patient's medical history or treatment.
Documentation Challenges
• Work environments- change management, variation• Information systems deficiencies• Complex years of transitioning from
paper-based to certified electronichealth record technology (CEHRT)
Work environments• The workforce of the future will likely look
different from the workforce we are preparing today. Best-practice culture and themes of:– Information sharing– practicing at top of license, – optimizing teams – Team STEPPS Strategies &
Tools to Enhance Performance and Patient Safety– provider experience satisfaction- joy at work– Interprofessional education
Work environments• Addressing shortages in nursing and primary
care and other settings pose many new opportunities and challenges.
• How well education and practice will work together toward a common understanding, and how to plan for shaping health care and demonstrating value to patients and health care organizations is already beginning to be demonstrated and experienced
Value of High-Reliability Systems?
• Safety and quality outcomes• Economics
Agency for Healthcare Research and Quality (AHRQ)
• High-reliability organizations are organizations that operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures.• High-functioning teams
Safety and Quality • Report Incidents, Near Misses and Unsafe
Conditions• National Benchmarking • PSOs and the Patient Safety Act of 2005• Just Culture• Safety Culture Nursing Peer Review• Team STEPPS Strategies & Tools to
Enhance Performance and Patient Safety
Economics and Business Case
•What’s in it for we?
Inter-professional Teamwork
• Inter-Professional Education (IPE) systems • (see new IPE map)https://nexusipe.org/informing/about-ipe
• Effective teams, effective nursing documentation
Documentation Opportunities
• Excellence• Transparency • Interoperability
Future Empowered Nurse
• Structural empowerment• Professional empowerment• Joy factor
Q&A•Questions? •Welcome for discussion
