1. Implementing Charting By Exception A Method for Streamlining Documentation and Making EPIC Work for Us Katherine Reynolds, RN Bobbi Schramek, MS, RN

2. Objectives Define Charting by Exception (CBE) and its benefitsDefine Charting by Exception (CBE) and its benefits Identify key components of CBEIdentify key components of CBE List at least 5 phases of CBE implementation in a major healthcare organizationList at least 5 phases of CBE implementation in a major healthcare organization Identify 3 challenges to CBE implementation and the strategies to address these challengesIdentify 3 challenges to CBE implementation and the strategies to address these challenges Identify 2 future considerations for CBE implementationIdentify 2 future considerations for CBE implementation

3. Overview Skepticism versus RegulationSkepticism versus Regulation Background for the projectBackground for the project DefinitionsDefinitions BenefitsBenefits PlanningPlanning Process RedesignProcess Redesign ImplementationImplementation EvaluationEvaluation Ongoing ChallengesOngoing Challenges FutureFuture

4. Skepticism against Charting by Exception Regulatory concernsRegulatory concerns –JCAHO –IDPH –CMS Legal concernsLegal concerns –Malpractice defense –Revocation of license

5. Regulatory Requirements Do not tell us how or where to documentDo not tell us how or where to document Do expect that our policies and standards are supported by the documentationDo expect that our policies and standards are supported by the documentation Do expect that the policies and standards of the organization meet the regulatory requirementsDo expect that the policies and standards of the organization meet the regulatory requirements

6. Legal Concerns Question of legality is same as regulatory concernQuestion of legality is same as regulatory concern Must show that policies, standards and decisions are supported by the documentationMust show that policies, standards and decisions are supported by the documentation Those policies and standards meet the legal and regulatory requirements.Those policies and standards meet the legal and regulatory requirements.

7. Age Old Cultural Belief The old adage, “If it wasn’t charted it wasn’t done…” is clarified in CBE as “If interventions, expected outcomes, and patient responses weren’t charted using symbols to reflect predefined norms-and variances weren’t charted in detail--then, it wasn’t done.” The old adage, “If it wasn’t charted it wasn’t done…” is clarified in CBE as “If interventions, expected outcomes, and patient responses weren’t charted using symbols to reflect predefined norms-and variances weren’t charted in detail--then, it wasn’t done.”

8. Background of CBE Project for ENH Epic implementationEpic implementation Practices of the paper world did not translate to the electronic worldPractices of the paper world did not translate to the electronic world Point of Care documentation mandatePoint of Care documentation mandate Super User Council concernsSuper User Council concerns

9. Evaluation Literature Search on Charting by ExceptionLiterature Search on Charting by Exception –Definition of CBE –Benefits of CBE

10. CBE—What is it? Charting by exception (CBE) is a shorthand method of documenting normal findings, based on clearly defined normals, standards of practice, and predetermined criteria for assessments and interventions. Significant findings or exceptions to the predefined norms are documented in detail.Charting by exception (CBE) is a shorthand method of documenting normal findings, based on clearly defined normals, standards of practice, and predetermined criteria for assessments and interventions. Significant findings or exceptions to the predefined norms are documented in detail. Murphy and Burke, 1990Murphy and Burke, 1990

11. Benefits of CBE Standards allow for consistent quality of care and documentation within organizationStandards allow for consistent quality of care and documentation within organization Abnormal findings are highlightedAbnormal findings are highlighted Repetitive documentation of routine care is eliminated through use of standardsRepetitive documentation of routine care is eliminated through use of standards  documentation time  documentation time

12. Evaluation and Recommendations Analysis of current practiceAnalysis of current practice Task Force FormationTask Force Formation

13. Phases of CBE Implementation Task Force Formation and EducationTask Force Formation and Education Analysis and Process redesignAnalysis and Process redesign Foundation WorkFoundation Work –Definitions –Policies –Regulatory compliance –Education Plan

14. Phases of CBE Implementation Development of Epic content and buildDevelopment of Epic content and build –Flowsheets –Care Plans ImplementationImplementation PI Plan for ongoing evaluation and performance managementPI Plan for ongoing evaluation and performance management

15. Task Force Formation and Education Multidisciplinary representation on the task forceMultidisciplinary representation on the task force Education of task forceEducation of task force –CBE definition and key components –Support materials for successful implementation Charge of the task forceCharge of the task force

16. Analysis and Process Redesign Key components of CBEKey components of CBE ENH analysis for key componentsENH analysis for key components Determination of what was neededDetermination of what was needed Change the culture of “If you didn’t chart it, it wasn’t done”Change the culture of “If you didn’t chart it, it wasn’t done” Change documentation processChange documentation process

17. Detailed Charting Charting by Exception NormalFindings Abnormal Findings Interventions Completed Intervention Variances

18. Key Components of CBE Standards and nomenclatureStandards and nomenclature Purpose specific documentation toolsPurpose specific documentation tools Point-of-care accessibility of documentation toolsPoint-of-care accessibility of documentation tools PI plan for ongoing evaluation of staff compliancePI plan for ongoing evaluation of staff compliance

19. Foundation Work Define Charting by Exception for ENHDefine Charting by Exception for ENH Develop documentation policies to support CBEDevelop documentation policies to support CBE Review for regulatory complianceReview for regulatory compliance Education PlanEducation Plan –Content –Timeline –Personnel

20. Epic Content and Build WNL definitionsWNL definitions Custom list and definition comparisonCustom list and definition comparison Assessment WNL rowAssessment WNL row Restructure of flowsheet templatesRestructure of flowsheet templates

27. Implementation of CBE Communication with all stakeholdersCommunication with all stakeholders –Superuser Advisory Council –Clinical Operations Council –EPICcare Meeting –Staff Nurse Advisory Board Staff educationStaff education Go-live of WNL flowsheetsGo-live of WNL flowsheets

28. Performance Improvement Plan Audit toolAudit tool Compliance audit scheduleCompliance audit schedule

30. Performance Improvement Data Staff re-educationStaff re-education

31. Percentage of Assessments using WNL Correctly Comparison by Facility

32. Performance Improvement Data Staff re-educationStaff re-education Validation of policies related to WNLValidation of policies related to WNL Validation of buildValidation of build

34. Challenges to CBE Implementation RN understanding of CBERN understanding of CBE Culture changesCulture changes Row sharingRow sharing

35. Future Considerations Culture changeCulture change Expanding scope of CBE without losing larger pictureExpanding scope of CBE without losing larger picture

36. Contact Information Katherine Reynolds, RN kreynolds@enh.org847-570-2999 Bobbi Schramek, MS, RN bschramek@enh.org847-570-2459