A great place to start: your patient hand-off process.
Without effective communication and efficient procedures for handing off patients from the emergency department to acute care, documentation is likely to be duplicated, causing an unnecessary drain on time and resources. Not to mention, asking your patients for the same information over and over isn’t helping to improve their care experience.
In your efforts to optimize organizational workflow, use the following tips to streamline your patient hand-off process and uncover inefficiencies.
1) Establish an order of operations for documentation.
Your community hospital’s emergency department should have an established policy and procedure for obtaining and recording the required patient documentation. Otherwise, inefficiencies occur – like when ED nurses who feel they don’t have time to handle this documentation pass it off to the receiving nurses on the inpatient side.
With a structure in place for what an ED nurse is expected to document prior to patient admittance, you’re apt to see an improvement in operational efficiency. The policy ensures that all employees understand exactly what documentation is required, when and by whom.
2) Keep all documentation in one place.
Develop one area of documentation in the EMR to gather routine information that’s used consistently from department to department, such as DOB and living will status, as well as past medical history (allergies, home medications, reported problems and procedures). This way, all users know where to find patient information quickly.
Operational efficiency suffers when clinicians have to trawl through the EMR to find what they’re looking for. If there’s one go-to place for entry and retrieval of patient information, the risk of having duplicate documentation or repetitive patient inquiries is significantly reduced.
3) Develop one hand-off procedure to be used hospital-wide.
In this procedure, both the reporting and receiving nurse should deliver the hand-off report at the patient’s bedside with the EMR in front of them. As the nurse performs a verbal SBAR (Situation, Background, Assessment, Recommendation) and cross-references the information in the EMR, everyone can review the documentation together to make sure it is complete and accurate.
4) Keep the patient involved.
Involving the patient in the hand-off process gives them an opportunity to fill in any “gaps” in communication and be more involved in their own care. Have your staff perform their reports with each patient to involve them more fully in the process and strengthen the lines of communication.
5) Monitor and continuously improve your process.
Implement an auditing process to ensure that documentation is completed effectively on a consistent basis. Managers should perform random chart audits to continuously improve the process. This would include reviewing the charts of admitted patients to see when the documentation was performed and whether or not the process was followed. Be sure to reeducate your staff as needed if deviations from the established process occur.
6) Go fully electronic.
Many community hospitals still use a paper Kardex for patient documentation – and not because of any EHR limitation, but because the staff prefers the familiarity of it. Often, this information doesn’t get entered into the EMR (to allow universal access for all caregivers) or isn’t transcribed correctly. Eliminating this data gap is critical.
Once a facility takes the necessary steps to refine its workflow process, the next priority is to make the patient hand-off and patient care documentation completely electronic. This allows end users to locate patient documentation more easily and provide better care for patients.
By using these tips to make the patient hand-off process as efficient as possible, you move several steps closer to improving operational efficiency at your community hospital.
But, there’s more work to be done. This is just one workflow out of many that you should be examining and adjusting to achieve better outcomes. The quality of care that your organization provides, as well as the satisfaction of your clinicians and patients, can be positively impacted by adopting a more proactive approach to operational efficiency.
Want to learn more about improving operational efficiency at your facility? Read our free whitepaper, 7 Best Practices For Community Hospitals.