Designing for the future of nursing records

HHF collaborated with UHN to design comprehensive nursing documentation forms that could easily be integrated into nurse practice, streamlining 48 different inpatient forms into two.

Client

University Health Network

In Collaboration With

UHN’s Collaborative Academic Practice (CAP)

Services

Ethnographic Research, Environment and Workflow Design, Co-Design Workshops

Challenge

In UHN’s busy clinical settings, nurses have limited time to conduct patient assessments and complete clinical documentation forms. Clinical documentation is a critical component of nursing practice. It provides the evidence of care provided and serves a communication tool among healthcare providers, so it’s crucial that they are intuitive and integrate well into nurse practice.

Across UHN, 48 inpatient units were each using different clinical documentation and workflows to conduct comprehensive head-to-toe assessments and document patient care. In addition, nurses were also using unofficial documentation methods to circumvent the limitations of these forms, including documenting everything as free text in the clinical notes rather than on the forms. The hybrid system of Electronic Health Records (EHR) and paper documentation further confused the process. In an effort to address the risk of patients receiving different assessments across UHN, which disrupts the continuity of patient information and compromises safety, we set out to redesign a single user-friendly form. In addition to allowing for more efficient and comprehensive documentation of patient assessments, the redesigned clinical documentation would also serve as the foundation once we implemented our new Health Information System (HIS).

The 48 variations of flowsheets that were used across UHN

“If it’s not documented, it’s not done”

Process

Our process was an active collaboration with nurses across UHN. Rigorous research, prototyping, testing, and refinements throughout ensured that the designs would be an effective and welcome replacement for existing documentation, and that they would achieve our goals of improving patient safety and the nursing experience.

Clinical Immersion

We kicked off this engagement with an in-depth immersion into the day-to-day life of a nurse. Through interviews, workshops and documentation reviews, we uncovered a few key insights.

What we discovered

The complexity of the forms made it difficult for nurses to extract and communicate key pieces of patient information

Nurses had little trust in the existing documentation process and, as a result, often double or triple documented in the clinical notes

Nurses found it unclear where information should be documented, and there was limited space to document information accurately

Patient safety was at risk as the forms did not meet nursing documentation standards (College of Nurses Ontario and UHN Policies)

PROTOTYPING &
Usability Testing

Effectively redesigning the forms alongside nurses required constant communication with stakeholders and rigorous usability testing. To test the content and design of the form, we conducted iterative usability testing sessions with nurses from various units in their own clinical environments. We created complex patient scenarios that were specific to each unit so we could observe how nurses would handle information on the form.

Piloting

While usability testing allowed us to validate the content and layout of the forms, we needed to ensure that nurses would be able to use them effectively and efficiently within their working environments. We conducted a three-day pilot in various units across UHN to test the form with real-life patient information, and to observe any workflow issues the nurses might encounter.

Qualitative data and feedback was collected through in-context observations. Additional feedback was collected at the end of each nurse’s shift, as well as through surveys that were sent following the tests. The key findings from usability testing and the pilot informed final refinements, and on November 5, 2018, the new inpatient form was launched across all UHN sites.

In addition to gaining valuable feedback on the content and design of the form, there were two key takeaways from usability testing and piloting:

The variance in workflow and practice for each individual unit highlighted the need for clinical notes to be integrated into the documentation
Some nurses would require more training on how to fill out the form, as some units were used to documenting everything in clinical notes

Outcomes

The rollout of these forms has ultimately transformed the workflow of 2400 nurses across UHN, and has allowed for complete patient assessments and care interventions to be properly documented. As UHN works towards the renewal of their Health Information System (HIS), these forms have built a strong foundation for the future of documentation across their sites: a future in which patient records are accurately recorded, communicated, and transferred to ensure the continuity and safety of patient care across UHN.

Download the forms