Implementing Charting By Exception

A Method for Streamlining Documentation and Making EPIC Work for Us Katherine Reynolds, RN Bobbi Schramek, MS, RN

Objectives

• • • • • Define Charting by Exception (CBE) and its benefits Identify key components of CBE List at least 5 phases of CBE implementation in a major healthcare organization Identify 3 challenges to CBE implementation and the strategies to address these challenges Identify 2 future considerations for CBE implementation

Overview

• • • • • • • • • • Skepticism versus Regulation Background for the project Definitions Benefits Planning Process Redesign Implementation Evaluation Ongoing Challenges Future

Skepticism against Charting by Exception

• Regulatory concerns – JCAHO – IDPH – CMS • Legal concerns – Malpractice defense – Revocation of license

Regulatory Requirements

• Do not tell us how or where to document • Do expect that our policies and standards are supported by the documentation • Do expect that the policies and standards of the organization meet the regulatory requirements

Legal Concerns

• Question of legality is same as regulatory concern • Must show that policies, standards and decisions are supported by the documentation • Those policies and standards meet the legal and regulatory requirements.

Age Old Cultural Belief

The old adage, “If it wasn’t charted it wasn’t done…” is clarified in CBE as “If interventions, expected outcomes, and patient responses weren’t charted using symbols to reflect predefined norms-and variances weren’t charted in detail--then, it wasn’t done.”

Background of CBE Project for ENH

• • • • Epic implementation Practices of the paper world did not translate to the electronic world Point of Care documentation mandate Super User Council concerns

Evaluation

• Literature Search on Charting by Exception – Definition of CBE – Benefits of CBE

CBE —What is it?

• • Charting by exception (CBE) is a shorthand method of documenting normal findings, based on clearly defined normals, standards of practice, and predetermined criteria for assessments and interventions. Significant findings or exceptions to the predefined norms are documented in detail.

Murphy and Burke, 1990

Benefits of CBE

• • • • Standards allow for consistent quality of care and documentation within organization Abnormal findings are highlighted Repetitive documentation of routine care is eliminated through use of standards  documentation time

Evaluation and Recommendations

• • Analysis of current practice Task Force Formation

Phases of CBE Implementation

• • • Task Force Formation and Education Analysis and Process redesign Foundation Work – Definitions – Policies – Regulatory compliance – Education Plan

Phases of CBE Implementation

• Development of Epic content and build – Flowsheets – Care Plans • • Implementation PI Plan for ongoing evaluation and performance management

Task Force Formation and Education

• Multidisciplinary representation on the task force • Education of task force – CBE definition and key components – Support materials for successful implementation • Charge of the task force

Analysis and Process Redesign

• • • • Key components of CBE ENH analysis for key components Determination of what was needed Change the culture of “If you didn’t chart it, it wasn’t done” • Change documentation process

Normal Findings Abnormal Findings Interventions Completed Intervention Variances Detailed Charting

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Charting by Exception

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Key Components of CBE

• • • Standards and nomenclature Purpose specific documentation tools Point-of-care accessibility of documentation tools • PI plan for ongoing evaluation of staff compliance

Foundation Work

• • • • Define Charting by Exception for ENH Develop documentation policies to support CBE Review for regulatory compliance Education Plan – Content – Timeline – Personnel

Epic Content and Build

• WNL definitions • Custom list and definition comparison • Assessment WNL row • Restructure of flowsheet templates

Implementation of CBE

• Communication with all stakeholders – Superuser Advisory Council – Clinical Operations Council – EPICcare Meeting – Staff Nurse Advisory Board • • Staff education Go-live of WNL flowsheets

Performance Improvement Plan

• Audit tool • Compliance audit schedule

Performance Improvement Data

• Staff re-education

50% 40% 30% 20% 10% 0%

EV 84 / 199 GB HP ENH 30 / 70 121 / 299 7 / 30 January, 2005

Performance Improvement Data

• Staff re-education • Validation of policies related to WNL • Validation of build

Challenges to CBE Implementation

• RN understanding of CBE • Culture changes • Row sharing

Future Considerations

• Culture change • Expanding scope of CBE without losing larger picture

Contact Information

Katherine Reynolds, RN [email protected]

847-570-2999 Bobbi Schramek, MS, RN [email protected]

847-570-2459