The case for simplification: How hospitals can get clinicians back to the bedside

Tasked with the need to comply with a vast body of changing regulations and the ever-shifting payer requirements for maximum reimbursement, hospitals have implemented a heavy load of clinical and operational policies in the name of compliance. As a result, clinicians are burdened with an enormous number of administrative tasks. These expectations, however well intended, actually place healthcare organizations at greater regulatory risk, reduce physician, nurse and patient satisfaction and negatively impact quality and safety.

This content was sponsored by The Greeley Company

A 2016 study published in Annals of Internal Medicine found for every hour physicians worked directly with patients, they spend about two hours on reporting and desk work. A 2016 Mayo Clinic Proceedings study found clinicians who use electronic health and medical records and computerized physician order entry report lower levels of job satisfaction and higher rates of burnout compared to clinicians who use paper.

The days of paper documentation may soon be in the past, leaving many in the industry wondering how to mitigate burnout while also complying with CMS conditions of participation, as well as reporting requirements that ultimately dictate reimbursement. Steven Bryant, president and CEO of The Greeley Company, a healthcare consulting, education and professional services provider, says the key to getting clinicians back to the bedside is to simplify expectations: get rid of unnecessary complexity in the documentation process.

"We have seen universally that hospitals' EHRs are so robust and overcomplicated that they deprive clinicians of adequate time to assess and evaluate their patients," says Mr. Bryant. "Regulations and reporting requirements are fairly cut and dry, but hospitals' own efforts to be compliant are overly complex. There's a real irony there."

Hospitals serve a lot of masters, but are often their own strictest taskmasters
It is the tendency of hospital leaders to think more is better when it comes to creating policies to ensure compliance with regulatory requirements. Therefore, hospitals' internal policies are often much stricter and more complex than federal, state and accreditation standards. This unnecessary complexity stems from healthcare professionals not fully understanding a standard's intricacies.

"What many healthcare leaders don't understand is that they must always comply with the strictest of the mix of federal, state, accreditation and internal policies," says Mr. Bryant. "When internal policies are drawn up and compounded to meet, but actually far exceed, federal or state requirements, they set a bar so high that it is hard to reach consistently, which then leaves a facility out of compliance. We have seen hundreds of facilities get into hot water with CMS because they can't meet their own impossible standards, but they would have met the federal requirements for Medicaid or Medicare reimbursement."

In hospitals, it is not uncommon to see a 20-page policy to address a single issue.

"Greeley's position is that healthcare organizations should never exceed a federal, state or accreditation requirement unless the added process enhances quality safety or revenue.  But they almost always do," Mr. Bryant adds. "Exacerbating this challenge is the inherent misalignment between the overstated policy, actual clinical practice and EHR documentation expectations. The time spent serving this many masters is time taken away from direct patient care."

How The Greeley Company gives time back to clinicians
A study published in the June/September 2017 edition of the Journal of Nursing Care Quality analyzed nurses' workdays and found that nurses spent nearly one-third of their time interacting with technology, with a combined 20.6 percent of their time dedicated to reviewing or documenting in the EHR. By contrast nurses spent a combined 16.1 percent on assessing and interacting with patients plus patient care and bedside procedures.

The Greeley Company's consultants are physicians and nurses who not only have a deep understanding of the regulations, but also understand clinical process and workflow. This allows them to help hospital leaders understand which parts of the documentation process are unnecessary and point out the consequences of inefficiencies.

"If a clinical process isn't practical and efficient, clinicians will find a way around it," emphasizes Mr. Bryant. "Clinicians want to do what's right and in their patient's best interests. If [you have to enter] 100-plus clicks and entries don't make clinical sense to them, it's not a sustainable process. An effective process must be one that drives quality and safety, but it also has to be efficient enough to be sustainable. Instead of 100 clicks, how about something you can do 100 percent of the time for an entire patient population?"

When hospitals enlist The Greeley Company to help them simplify their documentation processes, consultants first conduct a current-to-future state assessment. This assessment typically takes less than a week. The goal is to identify and quantify the clinical documentation reduction opportunities, and help the client better understand the Greeley methodology for simplification. The overall aim is to align a hospital's documentation processes, policies and clinician workflows, which Mr. Bryant notes is not easy, but very worth the investment.

In one success story, The Greeley Company worked with a Mid-Atlantic hospital to reduce the number of data entries clinicians input into their EHR. Greeley consultants found opportunities to reduce the admission assessment from 387 elements to 55 elements. On average, Greeley can reduce clinical entries into a hospital EHR by 70 percent.

How lowering EHR entries impacts the nurse's role
The role of a nurse has shifted dramatically over the years with the proliferation of the EHR. Gone are the Kardex and nursing notes — two very valuable communication vehicles that physicians valued, according to Mr. Bryant. The EHR has effectively transitioned the nurse from a critical thinker to a task-oriented resource.

"We need to trust in our clinicians and listen to them," Mr. Bryant says. "Nurses have critical thinking skills, and we have to remember nursing notes can be a vital, organic form of communication. If nurses are checking duplicative boxes all day, they have less time to make the observations doctors have come to trust."

The Greeley Company surveyed nurses from several different facilities before and after Greeley's simplification recommendations were implemented. Some notable findings include:

•    82 percent improvement in "Information is rarely duplicated in the EMR/medical record."
•    48 percent improvement in "I feel that the care I give is always reflected in the medical record."
•    55 percent improvement in "I can look at the EMR and get a clear story of why my patient is in the hospital."

Simplifying the process empowers clinicians to focus on patient care
Every hospital can benefit from improving efficiencies in the documentation process. Most importantly, efficient documentation enables clinicians to spend more time making eye contact with patients and less time looking at screens.  

"When a physician looks a patient in the eye and understands their concerns, a patient feels safe and will likely report higher satisfaction. If a clinician is running back to the EHR to input information, or worse, looking at a device or screen during a patient interaction, a patient may feel neglected and less included in their care decisions," says Mr. Bryant. "These erosions of the physician-patient relationship can be avoided through simplifying the documentation process, alleviating the administrative burden on practitioners, preserving (and restoring) the doctor-patient relationship and reducing clinician frustration and burnout rates."   

"Doctors and caregivers don't choose careers in medicine to perfect their data entry skills," Mr. Bryant adds. "Greeley specializes in distilling the required and finding the essential – simplifying the complex aspects of documentation and bringing reasonability back. These efforts at efficiency and practicality work to get doctors and nurses back to the bedside."

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