Standardization goes a long way in not only meeting the financial needs of the organization, but also the improved patient safety and care objectives. We can all agree that the ultimate goal of standardization is, in fact, patient safety resulting from clear, concise communication of evidence-based clinician instructions. Standardization can take on many forms such as approved abbreviations and data elements, common formulary items across facilities within a single enterprise, approved practice guidelines for core measure reporting, and defined structure during the ordering process.
The introduction of the EHR Incentive Programs and meaningful use core measures provided the ground work for organizational standardization measurement. The benefits of standardization still far exceed the challenges, the design/build once and implement/use many times is the foundation of good standardization.
For years, Medical Records Departments have defined the chart layout and what is and is not a part of the legal medical record. Prior to EHR adoption, chart assessment by this department and the resulting process streamlining allowed it to impose regulation and review body standards. It is because of this early entry into standardization that many organizations have left health information management (HIM) as the gate keeper of EHR standardization and compliance with an organization’s policies and procedures or standard operating procedures.
Pharmacy departments have long understood the need for and recommended standards such as requiring leading zeros when a decimal point is used, the use of complete drug names, and the adoption of an order format which lays out the sequence of the required elements of a medication order. The nursing community has since adopted these standards as the “five rights” of medication administration. However, as pharmacy workflow has changed and remote pharmacy personnel became more and more responsible for reviewing orders placed outside of their primary hospital, the need to standardize formulary became evident. Finance also quickly recognized the cost-savings benefits of a common formulary, and standardization allowed pharmacy and therapeutics committees to focus on common practices across the enterprise instead of at a single hospital.
As a result of the introduction of core measures, individual hospitals can now implement the policies and procedures required to meet the measure. Once workflow was defined for one hospital, it was logical to continue its use across the enterprise. This best practice has been reinforced by the increased use of a dynamic clinical staff that “float” from one operating unit to another within an organization as staffing needs require. Ordering providers have also recognized the benefit from a like standard of care perspective. By selecting a predefined group of orders, including medications, assessments and processes for others to follow, they can now better ensure that the patient is getting what they need.
Today, we have new regulatory standards for care (e.g., meaningful use criteria). These measures are designed to improved safety and reduced health care costs. In return, organizations receive monetary reward (or penalties) based on the standard achievement and demonstrated process improvements.
Computerized physician order entry (CPOE)
CPOE has resulted in standardized electronic processes that direct provider interaction within the EHR. In a paper environment, providers had spent years developing well thought out groups of paper order sets based on research, years of experience, and regulatory requirements. The transition from paper to electronic requires additional standardization:
• The format for all order sets should be the same, as well as the sequence of the orderable items;
• Orders sets should be reviewed by multidisciplinary across facility clinical content team that are aware of the current policies and procedures of the organization;
• Core measures and hospital policy items should be the same across all order sets (e.g., SCIP measures, VTE protocols, code status orders);
• Common departmental practices should be reflected (e.g., post-operative vital signs for all surgical order sets);
• Items that are preselected must not conflict with other items that are preselected;
• Orders like “Resume Previous Diet” or “Discontinue “X”” should be disallowed.
Standardization is a worthwhile activity whose benefits clearly outweigh the challenges. However standardization is never a onetime activity. Order sets should never be construed as static; they are dynamic and require regular review and modification. The time spent up front defining standards will save time over the long term and ultimately result in better patient care.
James E. Blohm, RN, is Senior Delivery Manager, and Deborah Wycoff, RN, MS, is Delivery Manager for CTG Health Solutions.