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Aligning Staff Workflows With the EHR Begins With the DNS

As of 2017, 66 percent of nursing homes used an electronic health record (EHR) in some capacity, according to the Office of the National Coordinator for Health Information Technology. However, directors of nursing services (DNSs) are not always taking full advantage of the capabilities these tools offer. “Implementing or optimizing an EHR is hard work, but like anything with nursing leadership, if you put that time in to build a culture, it will save you and your staff so much time down the road,” says Becky Kaufmann, RN, vice president of quality assurance and education for Lutheran Life Communities in Arlington Heights, IL.

The following steps can help DNSs and other nurse leaders either implement a new EHR or optimize the use of an existing EHR to align with staff workflows:

Start with the data

An EHR should provide DNSs and other clinicians with access to data that will lead to a solution of an identified problem’s root cause, says Kevin Whitehurst, senior vice president for Skilled Nursing Solutions at MatrixCare in Bloomington, MN.

“For example, many software platforms can run a report that says you have 10 residents with COVID-19 in the building, but that report often isn’t telling you why. You need to know how that happened so that you can figure out how to avoid additional cases,” he explains. “So, the first thing you should look at is: How are you using your data? Does your data only tell you what happened, or does it tell you why it happened? Do you have easy access to all of the data and analysis you need at your fingertips?”

Clearly understanding the team’s data needs can help DNSs make decisions about workflow changes to incorporate the EHR, says Whitehurst. “For example, many organizations will have staff manually gathering data at care plan meetings and using that information to determine how to manage risk. Changing the process to automate data collection and analysis means that risk management insights are at your fingertips, updated in near-real time. This will not only save a lot of time figuring out why problems happened, it will also free up time so they can spend more time on resident care and other critical activities.”

In the wake of COVID-19, DNSs should take a step back to look critically at all of their clinical systems, adds Whitehurst. “You need to take a holistic view and use this opportunity to streamline your processes, especially the way that you interact with the EHR. There may be opportunities to turn a four-step process into a three- or even two-step process, for instance, helping your team handle additional responsibilities, such as infection prevention and control, while still doing everything else they need to do to provide residents with quality of care and quality of life.”

Choose the least disruptive path

The EHR is a tool that is supposed to make staff members’ lives easier, not harder, says Whitehurst. “The reality is that staff don’t have time for distractions or onboarding a complicated new system. If they are going to change the way they do something, it has to be a pretty easy change. In implementing and optimizing EHR workflows, then, organizations should ask: How do we execute this in the least disruptive way?”

Have the right attitude

Leadership attitude drives EHR implementation and optimization, says Kaufmann. “An actively positive attitude is necessary to counteract staff resistance,” she explains. “Many staff members see EHRs as more cumbersome. With paper-based documentation tools, all they have to do is pick up the paper and start writing. With the EHR, they have to boot up the computer, sign in, and click multiple times to get where they want to be. They think, ‘I don’t have time to deal with the computer.’ However, we all know that the paper process is broken. Staff routinely do not document all of the things they should document on paper.”

Note: Resistance is stronger among long-term employees than among new staff, according to the December 2016 University of California at San Francisco research report, Health Information Technology Implementation: Implications for the Nursing Home Workforce.

There’s a definite difference in communities where leadership embraces and encourages EHR use, adds Kaufmann. “If leadership isn’t interested, some staff may not even show up to trainings. However, when management has a positive attitude, staff come to trainings, they are more open to learning, and they engage and ask more questions from the outset. A positive attitude is probably the most important step that any leader could take to jumpstart EHR use.”

The DNS is the leader who sets the tone for nursing staff, acknowledges Kaufmann. “However, the entire leadership team all the way through the organization needs to buy in, starting with the administrator or executive director. The administrator has almost as much influence with the nurses as the DNS does—and certainly has influence over other departments that may need to document in the EHR, such as dietary.”

Kaufmann offers this example of leaders “helping themselves to be successful”: Due to changes at the corporate level, a nursing home had to switch from an EHR that staff loved and that was managed in-house to an EHR that the facility wouldn’t have any control over. The management team did an implementation countdown complete with posters and t-shirts, and at the end of the training, leadership had the attitude, “We are so excited. Yes, we are losing some things that we really like, but we also are gaining some things that we really like. The new EHR will be great.”

Realize how long it may take staff to form new habits

Common wisdom holds that it takes 21 days to form a habit. However, research shows many habits take at least 66 days to form, depending on a variety of factors, including the complexity of the new habit, according to a blog on the PsychCentral website. “It makes sense that it would take more time for staff to form new habits using an EHR,” notes Kaufmann.

“First, your staff typically aren’t there 21 days in a row, and often neither are you. However, even if everyone is there, the workflow is different every day with an EHR,” points out Kaufmann. “You want to plan for at least three months of walking beside your staff every day to support and encourage them after the initial training and implementation. Leadership has to be committed to be there day in and day out to form those habits.”

Be aware of choice overload in EHR documentation tools

EHRs offer multiple opportunities to improve documentation, but sometimes choice overload can overwhelm staff, says Kaufmann. “The thought process behind some documentation tools in EHRs is that checkboxes make things easier because all staff have to do is find the resident’s symptoms, check them, and move on. However, if a nursing assessment is so extensive that it is 10 pages long (e.g., it includes a half-page respiratory section that includes 75 potential symptoms), nurses can become intimidated. They think, ‘I need to consider each one of these checkboxes,’ and they end up spending a lot more time looking at checkboxes than is necessary.”

In the long-term, DNSs may want to work with nursing staff and software vendors to ensure documentation tools find a healthy balance, says Kaufmann. “You may need to go back to the drawing board one or more times and ask, ‘How can we redo the forms to get the information that we need in a more compact package? Where is the real value?’”

In the meantime, however, nursing leadership needs to be side by side with staff on a daily basis—not once a month, not once a week, and not just when they did something wrong—to help nurses build documentation into their daily routine in a way that’s not detrimental to their workflow, says Kaufmann. “Going back to that 10-page nursing assessment, if the resident doesn’t have respiratory involvement, you should be there to say to the nurse, ‘Did you realize that you didn’t have to fill this out?’ or ‘Did you realize that you could have filled this out differently, and it would have gone faster for you?’”

Try a tip of the week

Finding the best ways to educate staff consistently over time may require some creativity, says Kaufmann. “For example, you could do a tip of the week—complete with a sign that you change weekly—on how to make charting easier. That way, you are encouraging staff and getting more bang for the buck without having to be one-on-one with each of them.”

Schedule bite-size projects

EHRs have multiple components that staff need to understand, says Kaufmann. “It can be beneficial to break down ongoing education into bite-size pieces that are appropriate to different types of nursing staff. For example, you might take a month to work on educating the nurses about how to best document an incident, while you have the certified nursing assistants (CNAs) work on documenting baths or meal intake. Then—every huddle, every day, every week for that month—you hit those topics hard for the relevant staff.”

Use internal stories to educate

Staff education about documentation should include the staff’s own stories, advises Kaufmann. “Showing how documentation did or didn’t help a resident at a facility five states away can work. However, if you reinforce education by telling the story of Mr. Jones two days ago on this shift and show how this entry was a great example of documentation that kept Mr. Jones from falling, got him to the hospital more quickly, or had some other positive outcome, that is so much more impactful because everyone loves Mr. Jones. Similarly, without calling out any staff, you can discuss staff documentation that resulted in negative outcomes to highlight the need for quality documentation.”

Find ways to help staff document in real time

Nursing responsibilities have multiplied during the ongoing staffing shortage, says Kaufmann. “Instead of having two nurses at the nurse’s station, you may just have one. That one nurse may be working with three CNAs instead of the five they used to have—and they’re the only one responsible for answering the phone and answering questions from families and the administration.”

Consequently, it is more imperative than ever that nurses document in real time as much as possible, advises Kaufmann. “For example, they could have a workstation on wheels or a tablet that they use either in the resident’s room, if possible, or just outside the door in the hallway. The nurse enters the room, does the assessment, and documents as they go in real time. At the end of the day, the nurse only has to review their documentation to see if anything needs to be added. The more documentation your nurses do in real time, the less they will have to remember, and the less they will sit at the desk. Sitting at the nurse’s station is an open invitation for the nurse to be interrupted and forget what they need to document.”

Some DNSs try to find middle ground by having nurses document on a paper worksheet in real time and then enter the assessment into the EHR later, says Kaufmann. “However, paper can get lost, and you want to improve your staff’s workflow by decreasing the number of times that they have to touch the information.”

Documenting in the EHR in real time can provide that workflow boost, says Kaufmann. “However, it takes practice for nurses to integrate that into their process. It also takes encouragement from nurse managers who will say, ‘Get out of the nurse’s station because you will be interrupted. I value your time. I value the information that you have, and I want to make sure we capture that. The further away you get from the bedside and the time you do it, the more it’s lost.’”

Look past traditional roles to free up time

Even with an EHR, carving out time to document can be difficult during a staffing shortage, says Kaufmann. “Obviously, resident care is the top priority. However, you should talk with staff and get their ideas about how to revamp their traditional roles to also allow time for documentation. For example, do the CNAs need to pass ice? To make beds? Or can someone else (e.g., temporary nurse assistants, housekeeping, etc.) take on those responsibilities so that the CNAs can practice their skills, including documentation?”


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