One of the most important components of the CNIO role is to help steer the organization toward standardization without negatively impacting the user experience. It can be challenging in any situation, but when you’re dealing with a merger that’s created a 50-hospital experience, the stakes become even higher. Fortunately for Providence St. Joseph Health, it’s an area Nancy Yates knows well. In fact, ensuring that nurses and physicians have the tools they need to deliver care has been a passion of hers for years.
In this interview, Yates talks about the strategy her team is employing to move to an integrated EHR platform, which includes applying lessons learned to subsequent rollouts, involving informatics in usability discussions, and striking the right balance in being nimble. She also discusses the digital rounding initiative that’s become a game-changer, the mobility platform her team hopes will improve interactions between nurses and patients, and the advice she offers for aspiring nursing leaders.
- Providence’s Question Bank – “It’s important to be able to benchmark against ourselves.”
- Arming nurses with mobility
- Leveraging IT to improve clinician-patient interactions
- “We’re getting closer. We’re not there yet.”
- From “clunky” DOS-based systems to EHRs
- Advice for pursuing nursing leadership roles
- “The beauty of nursing is that it’s so dynamic and flexible.”
LISTEN NOW USING THE PLAYER BELOW OR CLICK HERE TO SUBSCRIBE TO OUR iTUNES PODCAST FEED
It allows us to send messages to dietary and housekeeping so we’re constantly helping to improve the care experience. And it’s efficient — nobody has to pick up the phone. The more we can arm nurses with mobility, the more time they’re going to be able to spend with their patients.
Where it makes sense, we’ll use it to give the patient some control in their care. That’s going to go a long way toward helping them feel that they are part of the care team and are understanding their care.
I think the tools are evolving and getting better. If we took the EHR away from people today, they would scream and yell and jump up and down, but there are still opportunities to make it better.
If I was going to be the best nurse I could be, I needed to figure out how to make this technology work for me, instead of me working for the technology.
Whatever clinical specialty your heart is drawn to, let that be your foundation. And as you begin to use the tools, if you have a knack for making them work better and you’re one of those people that really gets into it, then informatics is for you.
Gamble: You talked about wanting to tweak here and there at some points, but is it difficult to maintain the balance between standardization and flexibility?
Yates: It can be, but as long as you continue to manage expectations, it can be done. We continue to evolve; we started off with 10 standard questions, and as the group started using the tool and we started seeing the data, the decision was made to have fewer standard questions and have some flexibility to be nimble.
Cipher has helped us create what we call the Providence Question Bank. Now we’re at six core questions because, again, it’s important to be able to benchmark against ourselves so we can see who’s moving the mark and what are they doing that’s helping to create a best practice. Then we start to really see the correlation between “these are all the patients who received a good quality round while they were in the hospital using the tool,” and the HCAHPS Score, so we can determine what they’re doing that’s better or different than anybody else. That benchmark is important, which is why we have to have a core set of standard questions. Each ministry is then able to decide they want to have two more questions that are specific to a focus area they’re trying to work in, such as noise, understanding care, etc. So they can go to the question bank and choose which questions they want as part of their script — that allows us to have that standard yet flexible platform.
Gamble: It’s really interesting when you look how patient experience is looked at and measured — IT adoption really seems to have played a key role in that. And you said there are plans to roll it out further across the organization?
Yates: It’s already live in five hospitals, I believe, and we’re preparing for two more.
Gamble: Okay, so obviously there’s quite a bit on your plate with the Epic migration. Is there anything else that’s a key focus for you at this point?
Yates: Another thing we’re looking to do is create a mobility platform specifically for nurses. The Orchid tool is one example of that. It demonstrates that you can have a device in your hand and interact with a patient while capturing real-time data, which can really drive care improvement. The beauty of this tool is it provides real-time information for service recovery. It also allows us to send messages to dietary and housekeeping, etc., so we’re constantly helping to improve the care experience. And it’s efficient — nobody has to pick up the phone. The more we can arm nurses with mobility, the more time they’re going to be able to spend with their patients.
We’re also working on Epic’s Rover Platform. We’ll be implementing that in a couple of our ministries as a pilot. What it does is it puts an iPhone into the nurse’s hand and allows them to do all of their point-of-care stuff tasks — medication administration, blood administration, specimen collection, some documentation, results review, and secure chats. Again, we’re trying to help them be as mobile as possible without having to haul a heavy work station on wheels into a room. They’re logged in already, so it saves time. The mobility platform is so important — not only in the acute setting, but also in the ambulatory setting. So we’re looking at what we can do to help in the same frame, not only with Epic but with Cipher Orchid. They have a kiosk which allows us to hand the patient a tablet so they can tell us how the experience was in the ED waiting room. We’re helping to take some of the burden away from clinicians to gather that data by putting those tools in the hands of our patients and letting them do it in real time.
The other piece to patient engagement is Epic’s MyChart Bedside Platform. We have MyChart deployed already in the ambulatory space; we have about 2.3 million patients enrolled. Now we’re starting to bring that into the acute care setting, and it’s a very similar process, meaning we give the patient an iPad and it allows them to see who their care team is. They can also access their schedule, they can view lab results as they come back, and they can message their nurses or providers with non-urgent things. And so, it’s creating a platform for all those tools to work together to engage patients in their own care. Obviously, not all patients are going to meet the criteria to have an iPad, but where it makes sense, we’ll use it to give the patient some control in their care. That’s going to go a long way toward helping them feel that they are part of the care team and are understanding their care.
Gamble: Right. And when you look at how IT systems were viewed years ago as a burden for nurses and physicians — as something that took them away from the patient, do you think that has changed? Are we starting to see a shift where more physicians and nurses are starting to leverage IT tools to have more face time with patients or give them the experience that they want?
Yates: I think we’re getting closer. We’re not there yet, in my opinion. We still have a lot of work to do — especially on the vendor side — to help create more and more efficiency. We have more work to do to let computers do more work for physicians and nurses; to present them with information versus the nurse having to go dig for it, and have more learning happening so that we don’t have to do the work that computers can do.
I think the tools are evolving and getting better. If we took the EHR away from people today, they would scream and yell and jump up and down, but there are still opportunities to make it better. Part of our challenge is balancing that with what’s required of us from regulatory and payment perspective and what we have to have in documents, or what can the computer do to help automate as much of that as possible so people aren’t a burden to the regulatory components of what we have to do. There’s still a fine balance there, but I think we’re getting there. We’re getting closer.
Gamble: It’s certainly not going to happen overnight. When you think about this, I’m sure you’re able to draw from your own experience as a nurse, and how these things affected you, and bring that perspective with you in this role.
Yates: Absolutely. I never lose sight of that. I was one of those early adopter nurses. I worked in a hospital that was implementing what they used to call clinical documentation systems in the early ‘90s and so, I was learning how to document in a DOS-based system on what I called an Etch-A-Sketch. It’s a full box. You had a stylus and you had to pick the number to describe and assess what was going on with your patient; it was extremely clunky. I remember the day I had the epiphany that if I was going to be the best nurse I could be, I needed to figure out how to make this technology work for me, instead of me working for the technology.
I was a pediatric nurse by clinical specialty. One day I was in the ICU and I had a child decompensate on me. We had to reintubate, put in lines, and resuscitate this child, and after all that was over, I looked at this little box and thought, ‘how in the world am I going to capture everything that just happened to this child in here? Where is my beautiful ICU flow sheet where I could have documented everything I’d written on paper towels, etc.?’ I called my trusty super user and said, ‘I need you to get up here and help me. Otherwise, I’m going to throw this thing out the window.’ I was so frustrated, but that was the epiphany moment of, I have to figure this out.
From then on, I became really interested in how we can use technology to help our caregivers, nurses, and doctors, versus having them work for the computer. That’s where my informatics journey began — it was before informatics nursing was really a thing. It became a specialty in 1994, and so throughout my career, not only in nursing leadership but as I helped implement these tools and improve them, it became my passion to make sure our nurses and physicians have the tools they need to deliver the care. It shouldn’t get in the way, ever. That’s a lofty professional goal, but I’m on the journey, and I continue to see us get closer and closer. We’re committed to being a part of that success story at the end of the day.
Gamble: You’ve seen it firsthand, from the Etch-A-Sketch to now.
Yates: Absolutely, implementing bad software and the impact it has on patients and those trying to take care of them.
Gamble: The thing I’d like to ask is, when you see younger nurses or nurses who are taking an interest in leadership roles, is there any advice you’d offer in terms of how they can start on that path?
Yates: For me, fundamentally, it’s making sure you have some clinical experience, because nothing builds credibility faster with those you’re trying to help deliver new digital tools than someone who’s walked in those shoes. So it’s making sure you have a clinical frame of reference and have actually used the tools to take care of patients so that you can understand what it means. And if you’re someone who is a system thinker — and that’s the beauty of informatics — it’s all about solving problems. If you like to solve problems and learn how the tools work and you want to have an influence over those, then informatics is likely your path.
The beauty of nursing is it’s so dynamic and flexible that you can do so many different things depending on what your passion is. So it’s getting a good grounding on what it means to be a nurse practicing at the bedside using the tools or in ambulatory space. Whatever clinical specialty your heart is drawn to, let that be your foundation. And as you begin to use the tools, if you have a knack for making them work better and you’re one of those people that really gets into it, then informatics is for you.
I lecture senior nursing students at our local university and I always share with them my journey and I talk about how to use the tools to demonstrate their professional practice, because at the end of the day, that’s truly what they’re accountable for. I give examples of good charting and not-so-good charting and encourage them to be a good example of what it means to use the tools correctly. It’s always fun to see the different reactions; some of them catch the bug, when they graduate, they get some clinical experience and enroll in a master’s program in informatics.
It’s also a good way to share what informatics is. Because, unfortunately, in most of the nursing schools, informatics is two or three pages in one of their books in leadership. And so, we have some opportunity to grow a better foundation. For nurses and physicians as well, it’s a fundamental part of how you practice, and you have to know how to use these tools. It’s imperative; it’s not an option. So the question becomes, how do we help build that into their education process so it’s not as difficult when they enter into practice?
Gamble: Right, you were a good person to address that question. Well, I think that about covers what I wanted to discuss. I want to thank you so much for your time. I really appreciate it, and I think this will be very useful.
Yates: You bet, thank you for your time.