NURS 6051: Transforming Nursing and Healthcare through Technology

Nursing documentation is essential for facilitating good clinical communication. Having appropriate documentation helps in providing an accurate reflection of pertinent patient information, care providers, clinical state changes and nursing assessments. This information is useful for supporting the multidisciplinary health care team in delivering the best possible care. With good nursing documentation, there is an assurance that evidence of care is available, thereby serving important professional function in showing nursing care provided, and meeting the medico legal requirement of nursing practice (Finkelman, 2019). This paper presents a proposal for a nursing documentation system that leverages technology to facilitate good clinical communication NURS 6051: Transforming Nursing and Healthcare through Technology.

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Description of the project

The proposed project seeks to leverage technology in delivering a nursing documentation system that provides information about patient characteristics, care delivered, and care outcomes. Nursing documentation is utilized to determine the reimbursement for nursing services, quality of care, intensity of nursing services, and severity of illness. Good nursing documentation is essential for good clinical communication as the documentation is aligned with the nursing process to reflect the continuous nursing principles of assessment, planning, implementation and evaluation. In leveraging technology and linking the nursing documentation system to the electronic health records (EHR), the information would be more readily available in real time to facilitate decision-making. This is especially useful for ensuring continuity of care as nurses and other medical personnel would be able to review the information on demand thus allowing them to continue providing the best possible care to each patient (McGonigle & Mastrian, 2018) NURS 6051: Transforming Nursing and Healthcare through Technology.

Stakeholders

There are five groups of stakeholders directly impacted by the project. First, technology vendors who would provide support in ensuring that the nursing documentation system is integrated into the EHR. The implementation of the project will affect other information systems used in the facility, and getting the vendor input is valuable for ensuring that the smooth integration of the system. In addition, vendors are helpful in identifying the support resources that can be leveraged, such as getting access to consultants who have extensive experience working with system integration, direct support from the vendor service team, and tools for facility staff use. Second, patients who are directly impacted by the project even as it alters their relationship with clinicians. It is valuable to consider the patients’ perspective in identifying technology-related projects that trouble them, to include accessing information in the system. The patients are the final customers of the nursing services and their experience matters in how the nursing documentation system is shaped. If the system alienates the patients, then the facility is likely to face a backlash. This makes it useful to consider the patients’ perspective (McGonigle & Mastrian, 2018)NURS 6051: Transforming Nursing and Healthcare through Technology.

Third, clinicians (nurses, physicians and technologies) who are the end-users of the system who interact with the system on a daily basis. Reaching out to the clinicians can have a positive impact on meeting the project objective and improving overall hospital efficiency as they would offer information on how the project impacts them and improvements that can be made. They have great value as: champions who would convince other clinicians to use the system, and super-users who assist others in using the new system. Fourth, facility leaders (from department leaders to chief medical officer, IT leader and CEO) who want to know that investing resources in the project will benefit the facility. Engaging them allows the project to gain credibility within the facility, have momentum, and keep moving effectively until completion. In addition, they provide information on the level of investment that would be allowed for the project, and ensure that the project goals are aligned with the facility’s overall priorities and agenda (McGonigle & Mastrian, 2018).

Fifth, audit and billing processes must be involved to ensure that they capture the right information for their functions. The project will have a significant effect on audit and billing processes, and should engage their staff as needed to ensure that the system is used as effectively as possible. In addition, they are involved in ensuring that the information is clearly coded and records meet audit needs. Besides that, involving them ensures that legal and regulatory needs are met in terms of the system design and archiving maintaining the best practices within the audit space. Failing to work with the billing and audit personnel can result in costly mitigation and late stage changes (Rivas & Wac, 2018) NURS 6051: Transforming Nursing and Healthcare through Technology.

Patient outcomes and care efficiencies

The project seeks to introduce a nursing documentation system integrated into the EHR. This is expected to improve patient outcomes and care efficiencies by saving on time spent in accessing nursing notes, and reducing the rates of documentation errors. Through saving on time, the project will improve efficiency of work time thereby allowing nurses to have more time for clinical care (McCarthy et al., 2019). In addition, the project will improve efficiencies in reporting for outcomes and benchmarking, presenting an audit trial to identify the work performed, and comply with accreditation standards. Besides that, it will back clinical decision and practice management tools to alert clinicians about errors and adverse interactions while tracking results and follow up. Additionally, it will present smart features that meet the needs of the clinicians as well as the patients who may access the information, and secure communication for coordination of care (Finkelman, 2019) NURS 6051: Transforming Nursing and Healthcare through Technology.

Technologies required

The project will require two projects. First, EHR as a digital version of the patient records, offering real-time, patient-centered information that is available instantly and securely to authorized users. Second, nursing documentation system that creates and addresses information included in nursing care plans, presents progress notes, and records patient assessments. The system will apply the DAR (acronym for: data, action and response) format that presents data collected during patient assessment, planned and implemented nursing actions for patient focused problem, and patient’s response to the nursing actions while evaluating care effectiveness (Rivas & Wac, 2018) NURS 6051: Transforming Nursing and Healthcare through Technology.

Project team members

The project team will have five members. First, project sponsor who will represent the organization in approving the project budget and access to required resources. Second, project manager who is responsible for overseeing the whole project and is accountable to the project sponsor and other team members. The project manager defines the project scope, timeline, expected benefits, costs, successful outcome, and how project will be closed out. In addition, the project manager ensures that the project is kept on time, on budget and within scope. Third, clinician champion who provides clinical expertise to communicate to the team how the project impacts the clinicians, and acts as a liaison between the clinicians and project team (Garcia-Dia, 2019).

Fourth, nurse informaticist who acts as a subject matter expert, lending critical advice on informatics expertise as needed. This includes evaluating and testing the system, documenting current and proposed future workflows to determine how the project affects daily jobs, and providing updates on the project. Besides that, the nurse informaticist is involved in system selection, defining policy and monitoring compliance. Fifth, trainer who works with the other team members to understand the affected workflows, and develop training material that are delivered to users to enable them use the system. Additionally, the training provides onsite support for the system (Garcia-Dia, 2019) NURS 6051: Transforming Nursing and Healthcare through Technology.

References

Finkelman, A. (2019). Professional Nursing Concepts: Competencies for Quality Leadership (4th ed.). Jones & Bartlett Learning, LLC.

Garcia-Dia, M. (2019). Project Management in Nursing Informatics. Springer Publishing Company.

McCarthy, B., Fitzgerald, S., O’Shea, M., Condon, C., Hartnett-Collins, G., Clancy, M., … & Savage, E. (2019). Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review. Journal of Nursing Management, 27(3), 491–501. https://doi.org/10.1111/jonm.12727

McGonigle, D., & Mastrian, K. (2018). Nursing informatics and the foundation of knowledge (4th ed.). Jones and Bartlett Learning.

Rivas, H. & Wac, K. (2018). Digital Health: Scaling Healthcare to the World. Springer International Publishing.

Assignment: The Impact of Nursing Informatics on Patient Outcomes and Patient Care Efficiencies In the Discussion for this module, you considered the interaction of nurse informaticists with other specialists to ensure successful care. How is that success determined? Patient outcomes and the fulfillment of care goals is one of the major ways that healthcare success is measured. Measuring patient outcomes results in the generation of data that can be used to improve results. Nursing informatics can have a significant part in this process and can help to improve outcomes by improving processes, identifying at-risk patients, and enhancing efficiency. To Prepare: Review the concepts of technology application as presented in the Resources. Reflect on how emerging technologies such as artificial intelligence may help fortify nursing informatics as a specialty by leading to increased impact on patient outcomes or patient care efficiencies. The Assignment: (4-5 pages not including the title and reference page) In a 4- to 5-page project proposal written to the leadership of your healthcare organization, propose a nursing informatics project for your organization that you advocate to improve patient outcomes or patient-care efficiency. Your project proposal should include the following: Describe the project you propose. Identify the stakeholders impacted by this project. Explain the patient outcome(s) or patient-care efficiencies this project is aimed at improving and explain how this improvement would occur. Be specific and provide examples. Identify the technologies required to implement this project and explain why. Identify the project team (by roles) and explain how you would incorporate the nurse informaticist in the project team NURS 6051: Transforming Nursing and Healthcare through Technology.

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Assignment (Week 4) To Prepare: Review the concepts of technology application as presented in the Resources. Reflect on how emerging technologies such as artificial intelligence may help fortify nursing informatics as a specialty by leading to increased impact on patient outcomes or patient care efficiencies. The Assignment: 4-5 pages (no longer) + title and reference page. Write a Project Proposal to the leadership of your healthcare organization, This is a Project Proposal, NOT a paper on a topic. Propose a nursing informatics project (needs to include computer technology) for your organization that will improve patient outcomes or patient-care efficiency. Be sure to use your course resources. If you have any questions about your idea for a project please email me! Sections for the Project Proposal should be (please use Level 1 headings for each of the following) Title Page Introduction and Description of the project. Include why this project is needed Identify the stakeholders directly impacted by this project. Explain the patient outcome(s) or patient-care efficiencies the project will improve. Be specific, provide examples. Identify the technologies required to implement this project Identify the project team members (by roles); explain how you would incorporate the nurse informaticist in the project team. Reference page. Use APA format; the sections listed above should be the headings for your proposal. Although remember APA does not use any heading for the Introduction section. Examples of Ideas for projects are listed here. Remember this should be a nursing project, or at least something nurses use regularly. If you are unsure, please email me. Nursing Staffing Planning System, Patient Acuity System, Incident Tracking System (electronic), eMAR (electronic Medication Administration Record) Nursing Documentation System Nursing Alerts in the EHR Others (as long as a nursing focus) Note: Often this is something you will purchase from a Vendor (most informatics nurses are not also software engineers!) Or it might be something your organization builds with your IT staff. If you are not sure about your idea, email me to check it out. FYI: AI (Artificial Intelligence) is a branch of computer science, it is NOT a Nursing Project Proposal. So your project should not be to “implement AI”, but it could be a component of the nursing system. Assignment (Week 4) To Prepare: Review the concepts of technology application as presented in the Resources. Reflect on how emerging technologies such as artificial intelligence may help fortify nursing informatics as a specialty by leading to increased impact on patient outcomes or patient care efficiencies. The Assignment: 4-5 pages (no longer) + title and reference page. Write a Project Proposal to the leadership of your healthcare organization, This is a Project Proposal, NOT a paper on a topic NURS 6051: Transforming Nursing and Healthcare through Technology.

Propose a nursing informatics project (needs to include computer technology) for your organization that will improve patient outcomes or patient-care efficiency. Be sure to use your course resources. If you have any questions about your idea for a project please email me! Sections for the Project Proposal should be (please use Level 1 headings for each of the following) Title Page Introduction and Description of the project. Include why this project is needed Identify the stakeholders directly impacted by this project. Explain the patient outcome(s) or patient-care efficiencies the project will improve. Be specific, provide examples. Identify the technologies required to implement this project Identify the project team members (by roles); explain how you would incorporate the nurse informaticist in the project team. Reference page. Use APA format; the sections listed above should be the headings for your proposal. Although remember APA does not use any heading for the Introduction section. Examples of Ideas for projects are listed here. Remember this should be a nursing project, or at least something nurses use regularly. If you are unsure, please email me. Nursing Staffing Planning System, Patient Acuity System, Incident Tracking System (electronic), eMAR (electronic Medication Administration Record) Nursing Documentation System Nursing Alerts in the EHR Others (as long as a nursing focus)  NURS 6051: Transforming Nursing and Healthcare through Technology