STANDARDIZING CLINICAL DOCUMENTATION: THE ROOTS OF THE ONE QUERY THEORY

When implementing a new system across an organization or enterprise, the system itself and the employees are often departmentally focused. While this may work well for each individual department, it creates somewhat of a nightmare for enterprise-wide reporting, as well as for patients. Many departments obtain identical information from patients that is then incorporated into their documentation within their module. The patient winds up being asked the same questions by each department they encounter.

This siloed approach means that when we talk about data we are collecting in MEDITECH, redundant queries are used to describe the same information.  New forms are created for documentation that meet the unique needs of each department, however, this results in redundancy per unit, per nursing service, and per hospital/facility. Most organizations do not take the time to identify shared queries resulting in a lack of standardization across clinical documentation.

The path described inevitably leads to the need to optimize and re-build the system, increased support staff, and a fractured record that makes important tasks like reporting nearly impossible. Implementing the One Query Theory is an effort to standardize queries across the enterprise. This will result in:

  • Better communication among clinical staff
  • Increased intervention visibility per specialty/department
  • Enhanced data collection
  • Greater standards of care adherence
  • Improved patient care

USING THE ONE QUERY THEORY TO OPTIMIZE THE ENTERPRISE-WIDE FLOW OF PATIENT INFORMATION

Efforts to implement the One Query Theory may be met with resistance from within the organization. First and foremost, team members are generally adverse to change. Each clinical area and discipline will most likely want to use their own terminology. Additionally, a lack of proper governance when taking on a project of this magnitude will surely result in failure. Intense effort is required to break down barriers and collaborate on what is ultimately best for the patient. Here are 4 key elements to successfully actualizing the One Query Theory in MEDITECH to optimize the enterprise-wide flow of patient information.

  1. Set goals for the project. Gather the organization’s executive sponsors and stakeholders to determine the objectives and goals for the project. These goals may be something along the lines of:
    • Standardize ambulatory documentation
    • Ability to access ambulatory data in an acute care setting
    • Build patient registries
    • Reduce wait times for follow-up appointments and scheduling procedures
    • Ability to share data across the enterprise to enhance the patient experience
    • Improved patient satisfaction and confidence in caregivers since data is collected only once.
  2. Create integrated design teams. For this project, your organization will want to create integrated design teams. We recommend two main teams, one clinical and one revenue cycle. The clinical team will be responsible for clinical documentation and clinician adoption, whereas the revenue cycle team will focus on scheduling and registration.
  3. Form work groups to standardize documentation. Jacobus recommends forming several work groups to work on standardizing documentation across the enterprise. The groups may look something like this:
    • Nursing Intake workgroup
    • Physician Advisory Committee (PAC’s are critical to achieving physician buy-in and satisfaction)
    • Social Work/Case Management workgroup
    • Registration workgroup
  4. Review and Evaluate MEDITECH standard content. Many organizations fail to realize the value of MEDITECH’s standard content. In many cases, this content is relevant and useful, although it may take some customization. In terms of nursing, as mentioned earlier, Jacobus recommends creating a nurse intake group from both acute and ambulatory nursing. From there, this group can set up rules to standardize without creating more documentation. Additionally, MEDITECH’s standard content for Admission Assessments can prove very useful. It is important not to dismiss this existing content without first evaluating if it is a fit for your organization.

These 4 key practices will set your organization up for success in actualizing the One Query Theory in MEDITECH to optimize the enterprise-wide flow of patient information. This effort to standardize queries across the enterprise will not only result in better and more accurate reporting and efficient communication across the enterprise, but improved patient care, and ultimately patient satisfaction, which is the end goal of everything we do as healthcare providers.

Interested in getting started with your One Query Theory project? Contact us to find out how Jacobus Consulting can help leverage your system to standardize queries, improve reporting, and patient satisfaction through collaborative efforts for a brighter future state.