Introduction
A patient care facility has the responsibility of delivering health care to patients in a timely, safe and effective manner. However, often, the overcrowded and unpredictable nature of care settings coupled by the fragmentation of care delivery system makes effective care delivery problematic. In particular, medication errors often arise due to “absence of information or incorrect information” (Bomba, & Prakash, 2005, p.68), which can have adverse effects on patient care. The passage of incorrect information results from ineffective communication modes used by practitioners during patient transition or administration of medication. A breakdown in communication especially during the end of shift handoff can have deleterious effects on patient care (National Patient Safety Agency, 2007). Thus, ineffective end-of-shift handoff resulting from either a poor communication modes or failure of medical records systems poses a risk to a hospital, the nursing staff and patient outcomes.
However, a standardized end-of-shift care handoff tool will reduce the risk of medication errors, improve patient safety and increase clinical staff and patient outcomes (Clancy, 2006, p. 416). In view of this, the Martha Hospital (MH), an acute care hospital, has recognized the need for a computerized clinical documentation system (CDS) for the surgical unit (SU) to address the problem of medical errors and promote service delivery. The implementation of a CDS during handoffs will involve Kotter’s model for institutional change to facilitate its adoption as a strategy for improving the patient outcomes and decreasing the risk of medication errors (1999, p. 118). Normally, the risks of medication errors arise due to failure to communicate the essential details of care between practitioners at the end of a shift (Queensland Health, 2007). The use of a standardized handoff tool will result to improved communication of critical elements of care, which will result to increased clinical staff satisfaction and improved patient outcomes in care settings.
Identification of the Need and Aim of the Innovation
The computerized clinical documentation system (CDS) patient care handoff will be a powerful strategy in MH healthcare setting. This mode of communication addresses the patient safety concerns, promotes patient nursing and medical care plans, and facilitates the continuity of care. At MH, the rate medication errors arising from poor communication between care providers at the end of a shift is high. The JCAHO report established that inaccurate or the lack of patient information often poses a risk to patient care (Croteau, 2005, p.11). Of the 2,966 medication errors reported between 1995 and 2004, 65% resulted from a breakdown in communication. Thus, the absence of systems and handover protocols increase medication error incidents and may jeopardize the safety of patient care.
According to Mathias “inadequate handoffs affect the patient care safety provided” (2006, p. 15). Additionally, the absence of a standardized patient care handoff in MH causes unnecessary delays in care and increases the risk of inappropriate treatment. This may lead to lawsuits and increases patient complaints over care delivery (Bomba, & Prakash, 2005, p.71). Therefore, the CDS will aid improve the safety of care interventions and mitigate the causes of adverse events at MH. A study of the medication error incidents by surgeons established that communication breakdowns contribute over 43% of error incidences with two-thirds of these incidences attributed to handoff issues (Bourne, 2000, p.60). Usually, physicians use a sign-out sheet as a common practice for communication. However, a study by Robinson, established that, 67% of the sheets bear errors such as incorrect or incomplete medication information, which result to adverse medical events (2002, p.187).
In addition, in terms of organization, hospital settings are becoming complex and disconnected each day and this intensifies the already existing communication woes in most organizations. One study established that, 23% of physicians had difficulties identifying nurses responsible for a patient at a given shift and this highlights the gaps that “exist in communication among practitioners especially when transferring information about a treatment at the end of a shift” (Horwitz et al., 2007, p.1472).
The Evidence
The handover practices in healthcare settings remain an issue due to high incidences of adverse events. The current handover practices include a combination of checklists or computerized systems within a care setting (DiClemente, & Velasquez, 2002, p. 211). According to Kuperman, the handover tools fail to focus on pertinent patient information essential in meeting the treatment goals (2003, p.35). Ineffective handover often results to wrong treatment, medical misdiagnosis, patient complaints and increased overall healthcare expenditure due to increase in the patient length of stay (New Zealand Resident Doctors’ Association, 2007).
Additionally, the ineffective handover tools are largely the cause of medication errors in care settings. In fact, ineffective handover practices account for 65% of medication errors in care settings (Groah, 2006, p.227). Thus, the development of evidence-based clinical hand-over tool is necessary for effective handover.
The dissemination of a standardized evidence-based handover tool to practicing clinicians is one way of facilitating its adoption (Broekhuis, & Veldkamp, 2007, p.112). This will be reflected in the communication systems of healthcare organizations such as MH. Additionally, the CDS, standardized with regard to timing and structure, will take into account the patient care needs and the potential of the patients or clinical staff to abscond. Bourne (2000, p. 64), found out that, the collaboration between nurses and doctors in sharing information and responsibilities was facilitated by expert communication. This implies that communication is central to effective patient care. Gandhi (2005, p. 352), established that, effective practitioner-pharmacist communication results to improvement in drug safety and proper management of pharmacy stock and dose systems for patients. In this way, medical errors arising from the administration of a wrong drug or drug overdose can be prevented. A standardized CDS will ensure that relevant information, including drug prescription, can be availed when required to prevent medical errors (Kelleher, 2005).
The Solution
The CDS handoff procedure for MH will provide the critical information regarding the patient, involve effective communication mode between the sender and the receiver and appropriately transfer the responsibility of care. It will be integrated into MH’s organizational systems and cultures that directly influence the patient safety. Thus, the CDS for MH will target the communication systems such as electronic or computer systems and the various caregivers involved in handoffs.
The CDS will promote interactive communication between the giver and receiver of care information. It will also provide up-to-date information regarding a patient’s condition, treatment and anticipated changes of patient health (Mikos, 2007, p.19). Since most hand-offs related medical incidences result from incorrect or incomplete patient information, the CDS will verify received information as well as provide feedback to recipients as appropriate. It will also allow the receiver of the patient information to review any relevant patient medical history including the previous treatments and services to assist in the choice of subsequent medical interventions (Rich, 2004, p.1350). The CDS for the surgical unit will comprise of a one-page electronic tool, which will be used for each patient. In this way, the CDS will provide a structured and comprehensive approach of providing pertinent patient information for postoperative patients and new patients to minimize handoffs-related medical errors.
The implementation of the CDS in MH requires the organizational support and commitment. Leadership promotes a culture of safety and learning, with regard to patient care, to prevent the recurrence of medication errors (Crum, 2006, p. 1061). Additionally, the diffusion of technology in an organization requires organizational commitment to adopt the CDS and maintain its usage.
The Organizational Change Strategy
The implementation of CDS at MH will involve an eight-stage stage of Kotter model of change that primarily focuses behavior change at an individual level (Kotter, 1999, p. 122). The stages include pre-contemplation, contemplation, preparation, action and maintenance.
Establish Urgency
The Kotter model states that, an individual is in a state of ignorance when a specified situation is outside his/her frame of awareness or need (Kotter, 1999, p. 123). At this stage, there is an intention to embrace change since the situation does not pertain to the individual (s). However, by establishing urgency especially among the practitioners over the importance of CDS with regard to facilitating effective shift transfer practices as a way of minimizing medication errors, will attract support for the initiative. A transitional oversight committee (TOC) will help in creating urgency on the benefits of CDS with regard to improving patient and clinical staff outcomes.
Create Powerful Coalitions
The argument for change often breeds a conflict where the existing practice has an established position (Chaboyer, 2007). To facilitate change, the TOC will not advocate for CDS vigorously, but will welcome views from the staff, administration, and patients on its implementation strategy. In this way, a powerful coalition will be created to spearhead the implementation of the CDS.
Sharpening the Vision
At this stage, the individual(s) have some level of awareness, and thus have objectives that are more specific (Kotter, 1999, p. 121). Once the staff and the administration become interested in the innovation, they become willing to learn about the change. However, at this point the feeling of procrastination may set in if they are forced to change. Thus, setting out clear objectives will ensure that the TOC remains focused.
Communicate the Vision
According to Kotter, sharing and communicating organizational goals informs the staff on the direction of the project (1999, p. 118). At this point, it is crucial to clarify the CDS goals as well as the cost/benefit tradeoffs of the CDS while accepting suggestions on how the organization will best adopt the change. The TOC will from time to time contact the staff and the stakeholders on the progress of the CDS implementation. The TOC will develop a systematic implementation process of the initiative. By implementing the project in stages or specified nursing units, the staff can feel the benefits, which will contribute to the full implementation of the project.
Remove the Obstacles
Kotter describes this stage as a point where a decision to remove impediments of the project is reached (1999, p. 127). Technological change is a gradual process and requires the involvement of staff and leadership. At this stage, creating an organizational culture of change especially with regard to use of new technologies is essential (Prochaska et al., 2000, p.117). It also helps to remove any assumptions or obstacles that aim at perpetuating the status quo and deter implementation of the CDS. The TOC will conduct staff training on the use of CDS practices and conduct an experimentation of innovation at selected nursing units. Since the implementation of the CDS in all units may be costly, the TOC will focus on acute patient care units such as the postoperative care units.
Short-term goals
Kotter (1999, p. 129) proposes the identification of short-term goals to allow the project to stay on course. At this stage, the TOC will highlight the CDS short-term targets as well as achievements. It will oversee the implementation of the project in most units of the MH with the participation of all stakeholders to avoid rejection. The TOC will be conscious of any relapse to old behavior and identify the contributing factors to old behavioral patterns.
Consolidate and Anchor
Kotter identifies this stage as a point where the new practices have replaced the old practices (1999, p. 126). At this stage, the CDS will be anchored into the general practice and does not require more planning. After the nursing staff at MH realizes the benefits of the CDS, they will want to continue with the intervention and the reversion into the old behavior is unlikely. However, occasionally, due to stress or during some given circumstance, reversion to old practices is likely. Thus, the TOC will still address the environmental cues that trigger the old practices such as the inconvenience of the CDS when retrieving patient data. The TOC will identify and streamline the triggering cues to reduce the possibility of reverting to old practices. The aim of maintenance is primarily to prevent relapse into old behavior patterns or practices.
Risks
The patient population is at risk of adverse effects that may arise due to a practitioner’s error during administration of medication after a shift change. Wrongful administration of medication due to incorrect or insufficient information provided poses a risk to the safety and welfare of the patient population resulting to adverse patient outcomes (Castledine, 2006, p. 524). Additionally, MH risks allocating funds to interventions that will not effectively reduce the medication errors over time. Consequently, the organization is at risk of facing litigation over medication errors or failure of service delivery due to limited communication between practitioners. This project also poses a risk as it takes many funds to implement and its failure will have adverse effects on the organization’s financial performance.
Business Planning
The planning process for the implementation of the CDS will first involve the constitution of the transitional oversight committee, which will comprise five experienced practitioners from MH. The members must share a common goal of transforming service delivery through acquisition and use of new technologies such as the CDS. Bunton et al., (2000, p. 67) argue that, the transformational leadership theory requires that transformational leaders be passionate, focused, inspirational and ready for change in order to achieve positive outcomes. In contrast, non-transformational leadership styles can have adverse effects on staff retention and patient satisfaction (Carr, 2007, p. 72).
After constituting the TOC, it will embark on developing guidelines for the implementation of the CDS project alongside the project goals and the budget requirements of the project. The business plan for CDS will comprise of three phases: project planning, project implementation, and project evaluation and dissemination. The funding for this project will be subject to approval at the MH corporate level. The project manager, a health records specialist, will guide the TOC in developing the project plan and budget. Additionally, the TOC will develop tools for monitoring and evaluation of the project progress.
The Budget
Funding at this stage will only cover the wages for the TOC members and the project manager. The next stage will involve conducting a CDS training to familiarize the staff with aspects of the CDS. Here, the funding costs will cover the wages for the project manager and the TOC team, booklets, meals and t-shirts for the staff attending the training. Regular assessment of the competency of staff under training with regard to use of CDS will occur under the leadership of the TOC. The training will take approximately six months. No additional funds will be required for the staff as the training will be part of their professional development. Additionally, the briefing and the in-service assessment of the staff will not require additional funding.
However, the dissemination of the project findings and promotional material will require additional funding. In particular, the brochures bearing the project introduction and conclusion, weekly electronic newsletters and project posters will require additional funding. Conferences organized in the final stages of the project, to disseminate the CDS results and promote nationwide adoption of the findings by all the target groups, will also require funding from the budget. In particular, advertisements in the local media about the conference, preparation of the conference programs and conference logistics, and conference presentation materials will all require funding from the project budget.
Evaluation
The final phase of the project plan will involve the evaluation of the project progress. The aim of evaluating the CDS project will be to determine if the implementation of CDS results to a decline in hand-offs related medication errors. The analysis of the data involving the error incidents from the postoperative unit will point to a decrease or an increase in medication errors. Weekly evaluation of the staff satisfaction will span the whole period of the project’s implementation. The evaluation of the project results will require the analysis of collected data and regular updates on the project progress to the staff. This will also require funding especially for the project manager during the duration of analysis of these results.
After analyzing the results of the project implementation, the project manager and the TOC will provide a summary of the project evaluation and recommendations. This will take place six months after the implementation of the project and will involve a survey of the patients/staff to assess their satisfaction with the project implementation. The CDS project targets to reduce medication in the surgical unit by 10% within the first six months of its implementation. The evaluation report together with the future recommendations will be conveyed to the staff during the regular briefing events.
Dissemination
Medication errors raise serious concerns to all stakeholders including the patient care settings and the health sector. The need to reduce the medication errors is central to health facility’s strategies for promoting patient satisfaction and safety. Given the implications of this project’s findings to the general practice, the dissemination of the findings from CDS implementation at MH will involve a public forum such as newspapers and magazines. This will highlight the hospital’s commitment towards reducing medication errors as well as improve patient safety. Consequently, it will act as a public relations strategy that will improve the image and the patient’s perception (Prochaska et al., 2001, p.254), of the MH as an organization.
Additionally, dissemination of the project details will also involve use journals for learning purposes and for use by other hospitals committed on improving patient safety. Dissemination to the other hospitals can also occur through a project presentation at Annual clinician’s conference attended by health practitioners from across the country. Dissemination of the project findings will also occur through State agency health websites such as the Queensland Health website and databases, such as the international nursing and medical journals, to communicate the findings to health facilities and provide a benchmark to other hospitals. It will also form a basis on which further research on technology use during hand-offs to promote patient safety and staff satisfaction. Dissemination to health researchers, through medical and nursing journals, will stimulate a discussion on ways the technology can reduce medication errors in other units in different care settings. The local dissemination by TOC of the project findings primarily to the nursing staff and practitioners will take an estimated period of two weeks to complete.
Conclusion
The traditional handoff practices at MH have not been effective at reducing the medication errors. Promoting patient safety in diversified and fragmented health systems is an essential step towards ensuring positive patient outcomes. In particular, most medication errors can be attributed to ineffective handoff practices. In view of this, the CDS project promises to decrease the handoffs related medication errors and promote patient safety and satisfaction. Using the Kotter model (1999, p. 118) of institutional change, the TOC will implement the CDS MH health facility in a systematic manner. Initially, the TOC will create awareness about the need to change the existing handoff procedures before the full implementation of the project. Regular monitoring and evaluation is necessary to avoid relapse into old handoff practices and promote the full adoption of the CDS procedure.
The evaluation of the project will also determine its success rate based on factors such as better patient outcomes, low medication error events and increased nursing staff satisfaction. The funding of the project budget is subject to approval at the corporate level. Dissemination of the project results will enhance the adoption of the CDS in other hospitals nationally as a benchmark for improving patient safety during handoffs.
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