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Publication Date

2022

Keywords

swedish learning 21; seattle; swedish

Disciplines

Health Information Technology | Nursing | Quality Improvement

Description

Background: Blood administration is a high risk, low volume, complex procedure. It has strict regulatory requirements for documentation of at least 15 elements over the course of the procedure. There are frequently findings for deficient documentation during survey. Manual audits are time consuming and inaccurate. Every facility in the Providence system faces the same challenges to audit for compliance.

Problem: Detecting the rate of compliance for documentation of blood administration manually is difficult. Nursing documentation for blood administration is often incomplete. Manual audits are labor-intensive and have proven to have limited impact to increase documentation compliance.

Methods: We created an automated audit to replace the manual process: To do so, we identified the required elements of documentation and studied the electronic medical record for the location of the documentation. This allowed us to create electronic reports from the Corporate Data Warehouse to retrieve the documentation data. Using the data source, we developed visualizations and analysis using PowerBI to understand where documentation was missing. The final report with visualizations were published as a PowerBI app.

Results: Improved documentation completion compliance, brought awareness to the standards for blood administration documentation, and enabled managers to monitor the rate of compliance is near real-time. The report allows managers to understand compliance at various levels of granularity: patient, nurse, unit, campus. For units that have adopted the tool, compliance rates have steadily improved. See table for examples.

Rate of Compliance by Unit

Unit

August 2021

December 2021

Swedish Cancer Institute

76.8%

87.7%

Swedish Orthopedic Institute

80.8%

84.0%

Heme/Onc 12 East

74.8%

88.7%

Discussion: This has simplified the task of auditing for compliance. The results are timely (T-1). Nurse managers’ report tremendous ease of use of the tool; training to use the tool requires less than 15 minutes. The tool is available for qualified stakeholders throughout the Providence system.

Next Steps: Continue to socialize the tool throughout the Providence system. Continue to refine the tool to meet the needs of individual unit standards and workflows.

Department

Nursing

Department

Quality

Department

Health Information Technology

Conference / Event Name

Swedish Learning and Celebration Day 2021-22

Location

Swedish Medical Center, Seattle

Blood Administration Documentation Audit Automation

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