Using electronic documentation as a decision-tree to facilitate and sustain a SCIP-9 improvement

Purpose:
An opportunity for improvement existed in SCIP-9 performance. Performance was at or below the national average. A needs assessment described the complexity that existed. The goal was to outperform the national average, ranking with the top 10 percent of hospitals and to sustain that improvement.

Significance:
It is established that the risk of catheter-associated urinary tract infection increases with duration of catheterization. The SCIP-9 measure, involving prompt catheter removal, is a Value-based Purchasing(VBP) measure. VBP participation is an aspect of health care reform that is expected to endure.

Strategy and Implementation:
Needs assessment gaps included knowledge deficits related to the SCIP-9 quality measure and best practice elements. In addition, there were no processes in place to trigger prompt catheter removal. Step 1 included education, order set and policy modification. Some improvement was realized, but the performance goal was not attained. The step 2 approach utilized an innovative application to address human factors. Imbedded in the policy was a decision-tree to guide nurses through the process of determining if the patient had surgical indications to keep a catheter, or instead, if removal criteria were met. The specific innovation involved remodeling electronic documentation to mimic the decision-tree guiding prompt removal. Documentation leads the nurse through a few items with approved indications as drop-down responses. If no approved indication for the catheter exists, the next suggested action includes removal with a real-time opportunity to document the action taken.

Evaluation:
The innovative strategy of imbedding a decision tree in electronic documentation assisted in sustaining a SCIP-9 rate of 100% for the past 12 consecutive months. This performance exceeds the top 10% of hospitals for this VBP measure.

Implications for Practice:
Imbedding best practices for clinical nurses in applications that already exist in their workflow seems to simultaneously facilitate the work of nursing and achievement of quality goals.