Photo by Christa Dodoo | Unsplash
Most health care systems across the globe are dealing with the reality of limited resources and staffing shortages. Therefore, it is more important than ever to ensure that health care professionals spend time on doing what matters most and providing the most value for service users.
Meaningful time spent face to face is a high priority for both service users and health care professionals. Paying more attention to computers than people because of the demands of burdensome documentation diverts our attention from direct care. It is a situation that is unsatisfactory for all parties.
The Danish municipality of Sønderborg, a safety leader in nursing home and home-based care for more than a decade, decided to see what could be done. With improvement science already embedded in their organization, they decided to take a deep dive into their processes as a first step. Mistakes in documentation, coordination, and communication have been identified as among the top 10 of root causes of patient safety incidents in Denmark, so it made sense to start there.
Patient safety is often cited as the reason for documentation, but some research indicates that burdensome documentation is associated with increased medical errors, mistakes in documentation, and burnout among health care providers. Working from the theory that safely simplifying or streamlining documentation would free up time for direct care, Sønderborg and the Danish Society for Patient Safety embarked on an improvement journey that started with understanding the workflow of documentation that enabled staff to seek and share information from one another to plan and perform different tasks. We also studied how paper and technology were used to record the care provided and measured time spent on different tasks.
Our data analysis indicated that there would be no quick fix. We found that workflow and documentation behavior represented the major causes of absent, incorrect, and duplicate documentation. This indicated to us that the culture of documentation needed to be addressed. Our analysis evolved into six drivers for the theory of change with culture representing a major part.
Every system is perfectly designed to get the results it gets, and we decided that changing documentation culture required a strong leadership message to build will and keep the line of sight visible for all staff. In Sønderborg, the message has been about how simplifying documentation would allow for more time with our service users. This has also been part of the hypothesis in all the change ideas tested using Plan-Do-Study-Act (PDSA) cycles.
Culture change often requires challenging assumptions. For nurses making home visits, these included “elderly people don’t want us to use computers in front of them” and “the computers work poorly on wireless networks in rural areas.” These assumptions led to nurses making notes on paper during visits and then copying them in the electronic record at the office at the end of their shift. By using the Model for Improvement to test change concepts (standardization and doing tasks in parallel), the visiting nurses developed a new practice for documentation. They now use their laptops to document home visits in partnership with their patients.
Challenging another accepted practice required building trust. Communication between shifts used to mean both documenting in the record and sending a note to all colleagues for each entry. This meant that people on the evening shift spent an average of 20 minutes on reading messages that duplicated what was in the record. By using the Model for Improvement to test change concepts (reduce excessive documentation and standardization), the frontline staff eventually implemented a new practice of communication that involved diligent use of the record and building confidence between shift colleagues to allow a reduction of reminder messages.
By taking a strong leadership role, the municipality of Sønderborg have improved the quality and simplicity of documentation and freed up time for direct care. The number of internal messages was reduced by 45 percent after testing and implementing a new workflow for coordination of care. To ensure one-step documentation, 93 paper forms and checklists were identified, reviewed, and when relevant, integrated into the electronic record. The only piece of paper to survive this improvement process was a printed list of a patient’s medications.
“The work Sønderborg and the Danish Society for Patient Safety has done to lessen the burden of documentation is a great example of how quality improvement work can benefit both patients and staff,” said IHI President and CEO Kedar Mate, MD. “It's also worth noting that it took courage to question accepted practices. Their years of building a culture of safety helped to reduce waste, increase value, and focus on what matters most to all.”
In the improvement community, it can be easy to “steal shamelessly” new ideas without first understanding the needs for change in our own system. We too often add another checklist or tool that worked in other settings without simultaneous exnovation. We need the courage of Sønderborg to step back, take a deep breath, and ask some important questions: How much or how little is necessary? How much time can we free up to do the things that really matter?
Vibeke Rischel is Deputy CEO at the Danish Society for Patient Safety and serves as IHI faculty.