Menorah Manor: CPOE and eMAR Implementation Findings

Category: Impacts and Benefits of Electronic Medication Ordering and Administration
Organization Name: Menorah Manor- The Bernard L. Samson Nursing Center
Organization Type: Skilled Nursing Facility/Long Term Care Rehab Facility
Author: Chief Nursing Officer, Anabelle Locsin, EdD., RN, LNC

Organization Description: The Bernard L. Samson Nursing Center is located within Menorah Manor in Saint Petersburg, Florida. The CMS five star ranked non-profit facility has 180 beds and was an early adopter of electronic medical records and electronic medication administration. The facility has embraced the volume of data available with the conversion to electronic medication administration and uses the outcome data to drive resident quality of care and workflow decisions. The facility enjoys an active census averaging roughly high 30’s-50 new admissions per month, depending on the season.

Project Description: The facility wanted to migrate from a paper based medication order and medication administration environment to Computerized Physician Order Entry (“CPOE”) and Electronic Medication and Treatment Administration (“eMAR/eTAR”). The project involved all levels of the Nursing Department and a complete evaluation of the paper based system before reengineering the workflow for the new electronic environment. The beginning analysis assisted the facility in identifying gaps in the process that had to be accounted for as part of the conversion. The project was accomplished in approximately 90 days from the point of project initiation to “go live”. Once the facility nurses mastered the basic workflow of converting from a paper based system to an electronic environment we implemented an automated bi-directional electronic interface to the pharmacy and also began a medication reconciliation process.

Implementation Approach: The facility took a team approach to the project. We established a core team of “Super Users” or facility experts that worked closely with the software project team on the various activities detailed in the project plan. I took the leadership role as the Chief Nursing Officer and was also the facility project leader and heavily invested in the success of the project. At each step of the project, the facility staff reviewed the current paper based approach and developed the new electronic workflow for the nursing staff. The facility used the opportunity to assess each step of the physician order entry and medication administration processes in order to identify ways to increase resident quality of care and increase nurse efficiency. The staff was able to improve efficiency and quality of care by building libraries of commonly used medication tests, orders and order sets. The team also evaluated the current facility infrastructure for network and hardware needs. This ensured the staff had the proper tools available to be successful in the new environment.

This approach allowed the team to incorporate best practices and established a group of in house experts in using the new workflow as an end product. This was critical to ensuring long term success of the project. The Train- the- Trainer approach gave the team the confidence they needed to be prepared for the training of 60+ nurses and the go live day. This team approach continues today.

Outcomes: The facility began utilizing the data immediately during the go live phase of the project. They were eager to begin comparing the new data to old. In the first month after go live; the facility was able to realize a 50% reduction in time spent on medication administration with the new electronic process. Ongoing order audits in 2014 reflect the improving accuracy and compliance; with Q1 of 91.4% improving to 93% for second quarter and most notable is June 2014 with 99.4 % compliance for new and readmission resident orders. Compliance for ongoing in house resident orders is a healthy 99% compliance rate. The night shift nurses audit all new orders entered throughout the day to ensure accuracy. The overall facility medication order error rate has decreased from 6%/1000 days to 1.6%/1000 days. Drug omissions have almost become a thing of the past with the alerts and monitoring available to the facility on the medication pass tablet and the electronic dashboards. The facility performs ongoing med pass procedural observations and audits with a 99-100% compliance rate. These ongoing audits are for all new employees as well as 6-10 of the current staff each month. The new electronic system offered resident allergy checking capability against the existing physician orders which also helped to reduce the medication error rate. The use of the efficiency tools available to the nurses shaved time off of new admission orders, readmission orders and commonly ordered medications and not only supported the goal of saving nursing time but also contributed to reduction in medication errors or missing orders. The electronic dashboard allowed senior staff to monitor new orders and medication pass data from a computer where ever they were in the building. The EMR system’s capability for remote access assisted in after hours support and monitoring of the new workflow by the staff.

The e-MAR tablets assisted the nurses with prompts and reminders for required documentation which improved charting compliance. The nurses were able to easily identify at a glance which residents needed follow up charting related to PRN medication administrations and other required documentation. The tablets also assisted the nurses in determining when the designated medication or treatment pass was completed which also contributed to a reduction in medication errors of omission.

The Quality Assurance team was able to analyze the new data available to them in real time to assess the success of the new workflow. They were able to build custom reports to monitor various types of high risk medication orders. They learned how using the various order category filters enhanced their ability to ensure resident needs were met and consistent processes were followed. The auditing allowed them to identify any nurses that were having trouble adjusting to the new workflow. Being able to have data that they could measure helped the success of the implementation.

The facility has been focusing on readmissions to the hospital and also admitting residents that are sicker and more complex. The readmission numbers are trending downward and this resulted in a compliment from one of our admitting hospitals. The comment referenced the low readmission rate and the positive working relationship between the hospital and the facility. In spite of the increase in admissions/readmissions, staff accuracy has been also been continuing to increase. Our admitting hospitals have commented that they appreciate the data from the electronic record when the resident does need to be transferred. The data is thorough, complete and easy to read.

As a result of the care and efficiency improvements, we have been able to provide meaningful continuing education programs for all staff regarding the top five diagnoses for readmissions to the hospital and of course covering all areas of their responsibilities, from assessments, communicating with the MD and families, and trying to prevent discharges to the hospital etc.

Better documentation has led to better financial outcomes. Requests for RAC reviews have been successful because of all the supporting documentation.   Skilled care reviews have become easier to follow when insurance companies request supporting documentation.

Lessons Learned/Advice to Share with Others:
When a facility starts the roll out, sufficient time must be allotted to making sure things are done correctly and to auditing to assure compliance, this contributed to the success. Interfacing with the pharmacy caused some growing pains but using the real time QA data process we have been able to ensure compliance as the new features have been added to the medication order and administration process. My advice to fellow facilities is to make sure to follow up with any individual staff (one-on-one) that have problems with compliance because the outcomes tend to be better. Getting the right education to the right staff at the right time has been successful for our facility. Educating the staff is not a one- time exercise. We usually schedule ongoing education with the staff during the year just to review certain aspects of the technology. This assists with discovering who does what correctly and who needs more re-education. We also bring in the more experienced nurses with admission orders to share their knowledge and assist the other staff in elevating their skill levels.

Include EMR training with orientation classes and good mentoring in the clinical area. “The Renew You Unit” (the facility short stay unit) is the busiest and with the largest number of admissions, so they we tend to expose new staff members to orientation on that floor. This allows new staff to become familiar with all aspects of resident care and exposes them to all the features of the electronic charting and medication pass software.

One-on-one follow-up with staff who are not in compliance tends to work in helping to elevate outcomes and staff performance. On a daily basis, I audit the previous day’s documentation and identify staff who need follow up and what they are missing. Sometimes, a gentle “love note” indicating what was missed quickly does the job. The nurses enjoy the ongoing feedback on the quality of their work and the personal attention from management signaling a job well done. The Nurse Managers follow through and if there are repeat “offenders” the process ensures communication with the individual nurses.

With a complete system properly utilized, management tools are available right at your fingertips.  You are able to see on a daily basis staff compliance with documentation and follow through with whatever the residents’ needs may be. Utilizing the medication reconciliation on admission and readmission promotes effective medical management of resident care.

In summary, our staff is more efficient and is better organized. The streamlined workflow has allowed the nurses to effectively handle the increase in admissions and also move the staff development activities to a model where they are expanding the nurse’s knowledge and skill sets. The new workflow has been a key element in assisting the facility to maintain its excellent level of resident care in the ever changing post acute environment. By using the team based approached to implementation, monitoring and ongoing feedback with education we have also been able to sustain a high level of staff satisfaction with no increase in staff turnover.