Running head: FINAL PORTFOLIO 1
Walden University – School of Nursing
NURS 6600C Capstone Synthesis Practicum – Nursing Informatics
November 11, 2015
4551 Canebrake Court
Powder Springs, Georgia 30127
Clinical Documentation Improvement Manager
Children’s Healthcare of Atlanta
Running head: POS and PDP 2
Table of Contents
Program of Study ………………………………………………………………………………4
Professional Development Plan (PDP)…………………………………………………………5
Portfolio Assignments from each of the following courses:
NURS 6001: ……………………………………………………………………………………….
NURS 6050: ……………………………………………………………………………………….
NURS 6051: ……………………………………………………………………………………….
NURS 6052: ……………………………………………………………………………………….
NURS 6053: ……………………………………………………………………………………….
NURS 6401: ……………………………………………………………………………………….
NURS 6411: ……………………………………………………………………………………….
NURS 6421: ……………………………………………………………………………………….
NURS 6441: ……………………………………………………………………………………….
NURS 6431: ……………………………………………………………………………………….
NURS 6600C: ……………………………………………………………………………………..
End of Program Outcomes Evidence Chart………………………………………………………...
Program of Study Form
Master of Science in Nursing, RN track
Based on the information that you provided, the following credits may be transferred into your program at Walden University.
This information is unofficial until all official transcript(s), international evaluation, and course description or syllabus is received.
Academic changes in the program you are considering may also influence the final review. For the most updated information
once you start your program, please refer to your degree audit located on your student portal.
Name: Lori A. Dixon Student ID Number: A00443635 Enrollment Date: 06/21/2013
Program: Master of Science in Nursing Specialization: Nursing Informatics
Transfer ofCreditMaximum: 40quartercredits
Course Title Credit
Transfer Course /
Term to be Taken
(Pre-Requisitesmustbecompleted priorto starting theNursing program and arenotincluded in thetotal credits)
NURS 6001 Foundations of Graduate Study 1 Fall 2013
NURS 3001 Issues & Trends in Nursing 5 Fall 2013
NURS 4001 Research & Scholarship for Evidence-based Practice 5 Winter 2013
NURS 4006 Topics in Clinical Nursing 5 Winter 2013
NURS 4011 Family, Community & Population-based Care 7 Spring 2014
NURS 4021 Leadership Competencies in Nursing & Healthcare 7 Spring 2014
(All core courses must be completed before starting the specialization courses)
NURS 6050 Policy and Advocacy for Improving Population Health 5 Summer 2014
NURS 6051 Transforming Nursing and Healthcare Through Technology 5 Summer 2014
NURS 6052 Essentials of Evidence-Based Practice 5 Fall 2014
NURS 6053 Interprofessional Organizational and Systems Leadership 5 Fall 2014
NURS 6401 Informatics in Nursing and Healthcare 5 Winter 2014
NURS 6411 Information and Knowledge Management 5 Winter 2014
NURS 6421 Supporting Workflow in Healthcare Systems 5 Spring 2015
NURS 6441 Project Management: Healthcare Information Technology 5 Spring 2015
NURS 6431 System Design, Planning and Evaluation 5 Summer 2015
NURS 6600C Capstone Synthesis Practicum 5 Summer 2015
Tentative focus for practicum experience: Total
Course Title Institution Grade Credits
Admissions Specialist Signature: Date:
Program of Study and the Professional Development Plan
Lori A. Dixon
NURS 6001: Foundations of Graduate Study
October 13, 2013
Program of Study and the Professional Development Plan
The purpose of developing a professional development plan allows me to record my
progress in lifelong learning and record my work as a scholar. My education goal is to receive
my master in nursing with a focus on nursing informatics. My professional accomplishments
and education are recorded in my portfolio, supplying a future employer with a history of my
education and career lifelong learning.
Education and Professional Background
In 1986, I was in a failing marriage, with three toddler children, and I knew that I would
have to be the parent who provided for my children. I lived in Dayton, Ohio and decided to go
back to school for my nursing degree. I attended Sinclair Community College and received my
Associate Degree in Nursing (ADN) in 1989. Within a month, I was a single parent providing
for three small children. My career began at the same hospital that my grandmother had become
a diploma nurse. I worked on a medical oncology floor and loved caring for patients. My
concern for patients led me down many career paths, from medical oncology to hospice, to home
health, and eventually to healthcare software. I was successful in my career and raising three
children; I had not planned on returning to school for my Bachelor of Science in Nursing (BSN).
Nurses are pictured as a woman or man in scrubs, leaning over and comforting a patient, but not
all nurses are on the frontlines physically caring for patients. Some nursing roles are supportive
of the clinical team that is touching patient lives on a daily basis. Do these roles impact the
patient? I believe they do.
Kim had HER2+ breast cancer diagnosed when she was only 36 years old, mother of an 11-year-
old daughter and married to her one and only love. She fought a hard fight, but after four years,
she died leaving her loving family. Her one wish had been to see her daughter become an adult.
I walked 60 miles for Kim, to help raise money for research to give other breast cancer patients a
chance at survival. Kim gave me a silver bracelet with a heart and pink breast cancer ribbon on
As a nurse involved in Informatics for over 20 years, I began to question how do I make a
difference in patient lives? Laptops and systems how do they help the patient? I believe I have
found the answer over the last year as I helped to open a specialty hospital for cancer patients.
Opening a new hospital, can be frustrating and I would rub the heart on my bracelet and
remember Kim. Combining the role of nursing and informatics, allows me to use my clinical
expertise to help make systems usage more than just a database. As I changed positions from an
IT Analyst to a Director of Clinical Informatics, using, this expertise made the difference in
opening the hospital.
As the building began to be under construction, I wore my hard hat and steel-toed boots as I
climbed stairs and reviewed various clinical areas to make sure that technically everything was
ready to facilitate patient care from the clinicians view, not that of a construction team or
technical team. Would placing computers at the bedside work best? Would the rooms still be
comfortable and home like to the patient? What about the nursing staff, did the information
system help them gather data to care for the patient better? It was more than just a building as
we had our Blessing Ceremony, and I wrote Jeremiah 29:11 on the concrete floor. Finally, on
August 15 we opened our doors, and our first patients began to arrive.
Kelly came on the Monday after our opening; she was breast cancer survivor with a new
diagnosis of stage IV anal cancer. She came looking for healing and hope, and what she found
was not just that, but new friends to support her journey. Last Thursday, I heard Kelly give a
patient impact statement. She did not talk about the fancy technology, or the fact that the
hospital was fully digital; she told stories. Her stories were about the clinicians, who found ways
to meet her needs emotionally and physically. Now she is in remission. I became a friend to
Kelly, and I wondered did I make a difference in her care. I believe it did! I trained the
clinicians to use systems that were designed to collect the data for her care and expedite that care
And yet is there more that I can do? My belief is that the future of healthcare will be more than
just recording the data in a digital record, but what can we do with that information? It is not the
system that is necessary it is the ability to retrieve the data, analyze it and make a difference in
Tomorrow is to today at my hospital. Now, we can do genetic testing to find out precisely the
type of cancer and what is the best treatment. I have a small part to play as an Informatics nurse,
but being able to retrieve the data rapidly and give it to our researchers and medical oncologist
will allow us to come up with treatments that meet the individual patient’s needs. Tomorrow, the
data that we provide today may make the difference between an HER2+ breast cancer patient
living four years or surviving to see her daughter grow to be an adult. It gave me the inspiration
to continue my career.
Being out of school for 24 years, the thought of returning to school was daunting. I have
presented at three professional association in my past on informatics and medication bar coding.
When presenting my curriculum vitae, I also felt a little shy with my lack of education.
Currently in my job, I also work with our research department on clinical trials. I use my
clinical and informatics expertise to transform the paper research protocol into a computer
pathway for physicians to follow. The ability to speak in front of others and to interpret clinical
data into software fields are my strengths. My weakness’ that I recognized on returning to
school was the ability to write in American Psychological Association (APA) style of writing.
Through this course, I have been able to learn how to write a paper in APA style and critically
review peer-reviewed articles. The sharing of discussion topics with other nurses has been an
incredible experience to learn about other areas of nursing.
Professional and Learning Goals
At 53 years old, why should I go back to school and earn my Master’s Degree? I have had a
fulfilling career and an excellent position at my hospital. I could work a few more years and
retire quietly, but I remember Kim and Kelly, and what the future holds for precision medicine.
Informatics needs clinician, who understand how designing makes a clinical impact on
information systems. That can use their clinical experience to affect the systems used to be more
than just a recording system for the chart. Today we discuss the sharing of information of health
information across systems, tomorrow we will be discussing how the sharing of that information
has saved patient lives.
A child of the 1960’s I never imagined being a ‘geeky nurse’, but I realize that to make a
difference, I need to return to get my Master of Science in Nursing (MSN). Becoming a scholar
and achieving my goals, will provide support to my career achievements. I hope to write in the
future peer-reviewed articles that will support the work I have done for several years.
I am looking forward to the practicum as I complete my studies. It will also be a challenge for
me to find a practicum experience in my area of study. Leaders in my hospital could be my
mentor for the practicum, but I want to find a place that will provide me with a new experience
and training in nursing informatics.
Online learning is giving me the opportunity to become a scholar-practitioner and meet my
professional goals. I have found that even challenging courses such as statistics, bring me new
information. I can use this knowledge when I do future research. I am looking forward as I
progress through my program of study, nursing informatics, and when I graduate from Walden
University in November of 2015.
Lori A. Dixon, R.N., CDIP
email@example.com Powder Springs, GA 30127
Powder Springs, GA
Lori Dixon, R.N., CDIP, Nurse Informaticist
ClinicalInformaticsprofessionalwith over 20 years of experience. Experience with informationsystems including:
development,support,project management,implementation,trainingandmaintenance. Leadingfromthe
intersectionof clinicalpracticeand informationsystems to developthe integrationof technologyandhealth-careto
improvepatient outcomes.Analysis of clinicalandfinancialdatato providegapanalysis,andbuilddashboardsto
Informatics career distinguishedbytheuniqueabilityto buildcollaboration,movepeople,projectsand organizations
forward. Outstandingcommunication,negotiationandrelationshipmanagementskillsfoster anatmosphereof
cooperation,efficiency,productivity andqualityof care. Visionaryleadershipstylewith the abilityto inspire
confidenceinothers andcreatively solve problems,remove obstaclesandachievebreakthroughresults.
Qlikview – DesignerVersion 11.2 training
Createtrainingand educational material
Work Experience Highlights
Children’s Healthcare of Atlanta August 10, 2015
Clinical Documentation Improvement(CDI) Manager
Responsible for developing new CDI program at pediatric hospital.
Responsible for hiring new CDI nurse specialists and ongoing managementofup to eightnurses.
Education of clinical staff and physicians on appropriate clinical documentation to supportpatient
Responsible for developing future program for outpatient CDI.
Santa Rosa Consulting May 2015 to
ICD-10 Educator and CDI Auditor
Stamford Health System
ProjectManagementofICD-10 training for physicians, CDI, and other hospital staff
Work with CDI staff to create queries to be builtinto Meditech
Auditing with HIM staff of 1000 charts for retroactive coding to ICD-10 and responsible for clinical
documentation audits in charts.
Audit ofCDI program for possible workflow and program improvements
Developing CDIqueries specific to pediatrics, neonatal intensive care, and OB.
Developing bootcamp for CDI certification through AHIMA for hospital CDI program.
MMY Consulting April
2014 – April 2015
Senior Clinical Consultant
Gap Analysis of ICD-9 diagnosis and procedure codes by physician specialty for CDI and
Conversion ofICD-9 to ICD-10 for diagnosis and procedure codes
Program manager for ICD-10 and workflow testing. Analysis ofICD-9 data to create appropriate
testing scenarios based on clinical and financial business. Round one testing completed with clean
claims submitted to national clearing house. Responsibilities include creating testscripts,
workflows, and coordinating scheduling.
Responsible for assessmentofICD-10 readiness for 21 hospitals within a large Midwestern health
Interviewed and educated 25-30 departments at each hospital.
Created process flow charts for each department’s workflow, with applications being used,ICD
coding being done, and reports needed.
Worked with new clinical documentation improvementspecialists (CDS) on how to have physicians
appropriately documentbased on specialty and medical diagnosis to supportthe diagnosis.
Created over 90 test scripts based on application and process flow for health system.
Coordinated testing with end users, application analysts, and desktop services. This included
making sure that testing laptops were setup with test applications and had been updated to ICD-10
Functional testing and partial integrated testing completed ateach hospital. Testing documentation
signed offby departmentdirectors and database setup to hold testing results.
Cancer Treatment Center of America August 2009 –
Director of Clinical Informatics
Created dashboards using Qlikview, reporting to executive team and quality.
Developed and ran queries in SQL to meetdata needs.
Developed 21 reports to retrieve data for Blue Cross/Blue Shield ofGA contract, resulting in
meeting all quality measures and bonus points.
Assisted with The JointCommission accreditation with no deficiencies.
Monthly reporting for CPOE and bar coding percentage. CPOE is over 90% for physicians.
Medication barcoding ofmedications is 95%.
Worked with research to develop research protocols in clinical applications and to retrieve data to
assistin finding patients meeting research protocols.
Served on Cancer Accreditation Committee and Breast Cancer Center of Excellence for analyzing
data needs and changes to clinical systems.
Responsible for ProjectManagementfor the implementation ofAllscripts Sunrise Clinical Manager,
Medication Manager, and Knowledge-Based Medication Managementfor opening ofthe Atlanta
o Developed projectschedules and timelines.
o Managed projectschedules and status reporting efforts. Prepared and presented status
reports to executive management.
o Worked with Information Systems and Director of Informatics from four sister hospitals to
coordinate configuration changes to the systems.
o Created design specifications for changes within the system.
o Performed troubleshooting ofissues to determine ifthey were a defector education issue.
o Consulted with physicians for enhancements needed to clinical applications then
ProjectManager for ancillary systems: Varian, RIS, SunquestLab, Enterprise Scheduling, Hyland
Record Management, and Quadramed Acuity system.
Responsible for projectmanagementofupgrade from Allscripts products from 5.5 to 6.1.
o Led upgrade efforts tracking schedules, implementation timelines and roll out.
ProjectLeader ofimplementation ofmedication reconciliation effort.
Responsible for education ofover 650 clinical stakeholders, which included physicians, nursing,
and ancillary stakeholders.
Educated physicians on proper documentation to supportmedical diagnosis, and how to do that
within the clinical applications.
IT Site Liaison
Facilitated and communicated IT issues between corporate IT and facility.
Supported hospital executive team during construction offacility.
Senior Clinical Analyst
Performed configuration and supportofAllscripts Bar Coding and Pointof Care Applications.
Allscripts August 2004 – August
Provide mentoring to staff and clients. Created and presented classes on various components of
Sunrise Clinical Manager product.
Onsite Consultation with Clients to provide auditofsystem, problem resolution and
Troubleshootconfiguration issues for Sunrise Clinical Manager components.
Specialize in Sunrise Pharmacy issues, provide problem investigation and resolution to customers
for Sunrise Clinical Manager.
Floyd Medical Center Home Health July 2004 –
Home Health Case Manager
Responsible for Medicare/Medicaid/Insurance authorization.
Managed case load of25-30 visits per week, including pediatrics, infusion.
Patient Care Technology software used, assisted in office with clinical information system.
End user documentation in the field using laptop, responsible for completing documentation daily
and downloading back to the office.
Wellpoint CostCare/Unicare August 2003 –
Senior Clinical Trainer
MedCall is a call center supporting patients insured by WellPointbrand insurances.
Responsible for new hire orientation, Breastfeeding and ClientTeaching/Documentation class.
Testing and training of computer systems used by staff.
Monthly education newsletter. Audits ofstaff documentation. Silentmonitoring ofcalls. Triage calls
Assisted unitin preparation for URAC accreditation, full accreditation received March 2004.
Northside Hospital – Cherokee May 2002 –
Bariatric Program Coordinator
Education of patients and staff. Patient visits in office (30 per day).
Coordinate insurance coverage. Coordinate care between hospital and office. Clinically responsible
for office functioning.
Assisted surgeon in initial setup ofmedical office.
Patient Care Technologies May 1997 –
Senior Developer/Marketing Representative/Consultant
Designed reports based on industry standards for reporting on Home Health and Hospice data.
Developed software to meetHospice and Home Health Care regulations, Medicare, Medicaid and
Prepared and presented marketing materials to agencies and hospitals.
Fidelity Home Health 1995
Clinical Computer Specialist
Responsible for design and setup ofnew computer system.
New Federal Regulations released for PPS (Medicare Billing).
Worked with vendor to setup design ofsoftware using the new requirements from the Federal
Designed training program and materials with approval for 38 nursing CEU from Ohio Nursing
Implemented McKesson HBOC/MSIcomputerized charting, billing and scheduling system with
Previous healthcare background includes roles with increasing responsibility –
Staff Nurse, Clinical Computer Specialist/Infusion, Supervisor Clinical Director
Implementation of Patient Care Technology clinical software with home health agency.
Responsible for JCAHO accreditation.
Hiring and supervising clinical staff, writing and maintaining policy and procedures.
Implemented Siemens/Delta Computer system for administration, billing and clinical for home
Patient care load of5 patients including documentation on clinical computer system, including care
planning, orders and results. Medications were the only item still on a paper MAR.
MSNNursingInformaticsStudent,WaldenUniversity – GraduationFall2015
The UnSummit– Workflow, Design and Technology ofMedication; Administration Technology: Putting the
Pieces Together for Successful Outcomes; Allscripts EUN– Implementation ofBar Coding; Allscripts– Two
Sessions – Configuration and Implementation ofIV Fluids with a EUN multidisciplinary approach and
Troubleshooting Pharmacy Logs. Home Health Care Association – Electronic health records in home
Developing a Health Advocacy Campaign
Policy & Advocacy for Population Health
August 10, 2014
Developing a Health Advocacy Campaign
Nurses have an ethical responsibility to be active in advocacy. Nurses should address
issues with populations, and speak out to make changes in disparities or inequities to access to
care (Laureate Education, Inc. [Laureate], 2012). The purpose of this paper is to describe a
population health issue, identify the population it affects, review current health advocacy
programs and develop a health advocacy program.
Population Health Issue
The Affordable Care Act (ACA) is designed to provide healthcare for all Americans.
The emphasis is “all Americans.” To be eligible for care, an immigrant must have legal
immigrant status ("ACA Latinos," 2014). Migrant workers in the United States are a mixture of
legal and illegal workers. There are nearly a million farm workers, and 25-50% are illegal
immigrants (Baragona, 2010). Farm workers have families that travel with them from state to
Patients go to a new provider, and the first thing that happens is the collection of their
health history. The new provider may ask for a release to get medical records from a previous
provider. Illegal or legal migrants move so frequently that they do not have a primary health
care provider. They may seek emergency or urgent care when they become ill, and children may
not receive important check-ups. There are barriers to healthcare such as unable to speak
English, the cost of care, availability of care, and distrust of healthcare workers. Hispanic
workers have health issues such as diabetes, sexually transmitted disease, teenage pregnancy,
and cirrhosis (Peach, 2013). The health issue is a lack of healthcare due to barriers that prevent
migrant workers and their families from receiving consistent healthcare. By traveling from state
to state, there is no history of their medical care for new providers to review.
There are over 400,000 children working on farms in the U.S. Once they reach the age of 12;
children are allowed to work in the fields. But children as young as six, have been found
working in the fields. Mexican-American migrant children are two-three times more often in
poor to fair health (Waldeman, Cannella, & Perlman, 2010). They are exposed to pesticides and
go without having acute illnesses treated.
Health Advocacy Program I
The University of Southern California School of Dentistry (USCSD) has a mobile dental
program to serve migrant children (Mulligan, Seirawan, & Faust, 2010). Dental disease is rated
in the top five health issues for the migrant workers in California. Six communities were visited,
and the prevalence of tooth decay in children was 87.4%. As part of the curriculum for dental
and hygienist students is a community service component. This provides them experience in
their field and educates them on cultural differences. The program has operated for 40 years and
returned annually to up to 70 communities.
The program has five mobile vehicles, and one is set up for supplies and sterilization.
The team shows up with all vehicles at a community site such as a school at least a week in
advance (Mulligan et al., 2010). The Migrant Education Program refers the children, and before
the child can be treated the team must get parental consent. Faculty, residents, and senior
students perform complete exams including x-rays and health histories. The program receives
funding from grants and community sponsorships.
Attributes of USCSD Mobile Dental Program
The program is a safety net for migrant children’s dental health issues. Healthy People 2020
have the objective OH-2 Reduce the proportion of children and adolescents with untreated dental
decay (Healthy People 2020 website, n.d.). There are two attributes that make this program
effective. First, students are used to providing the services to the children. It provides care to
the underserved and gives the students experience in their field. The second attribute is
volunteerism in the communities they visit. The students are there for a limited amount of time,
and many of the children need extensive care beyond what can be done during the visit.
Ongoing care is coordinated with the dentists in the community who have volunteered to help the
children (Mulligan et al., 2010).
Health Advocacy Program II
The Farm Worker Family Health Program’s (FWFHP) is run by Emory University School
of Nursing and Ellenton Clinic, which is a local community clinic (Connor, Layne, & Thomisee,
2010) through a small grant, FWFHP started in 1993 and has grown to 15-year multidisciplinary
academic-community join venture. Local community agencies they work with include summer
education program, businesses, faith communities, childcare centers, the Area Health Education
Center (AHEC), farmers and growers, and others (Connor et al., 2010).
Three urban universities and local college participate every summer. They travel to rural
Georgia where they live and work for two weeks. Approximately 90 students and faculty
members including nursing, physical therapy, dental hygienist, and psychologist care for
patients. Returning students and faculty provide continuity of care each year (Connor et al.,
Care is provided in a clinic setting, and the team goes to where the patients may be such as
daycare centers. Nurse practitioners perform head to toe exams, and student nursing assess
height, weight, body mass index, vision, hearing, blood pressure, hemoglobin, and glucose.
Dental hygienist clean teeth and provide fluoride treatments. Physical therapy students teach
body mechanics (Connor et al., 2010). FWFHP recognizes the cultural values of the migrant
workers and educates them on chronic illness and preventive care.
Attributes Farm Worker Family Health Program’s (FWFHP)
The program is not dependent on government resources or insurance to run the program. They
use grants and community programs that are in place. Barriers to care are avoided because they
go to where the migrant workers are working or where the children are in an education setting.
They also run a clinic from early in the morning to well after midnight to meet the needs of the
migrant workers who may work 16 hours a day in the fields (Connor et al., 2010). Another
attribute is that they also work within the culture of the patients and recognize the differences.
Finally, they use university students in nursing, dental, psychology, and physical therapy to
donate their time. It provides care to the patients and gives these students real-life experience in
The National Advisory Council on Migrant Health wrote a letter to then Secretary
Sebelius recommending health care needs of the migrant population (National Center for
Farmworker Health website, 2014). They recommended increasing the funding for primary care,
outreach, chronic care and health care workers. Despite the ACA being enacted, there are
barriers to care, especially for access to the care and illegals being part of the population. There
are over 400,000 migrant children that may be working in the fields and exposed to pesticides
(Waldeman et al., 2010). These children also move from place to place. They may either have
too many immunizations because of a lack of records or not enough immunizations
(Connor et al., 2010). There is currently a pending law called the HEAL Immigrant Women and
Families Act of 2014 and was introduced in March 2014. H. R. 4240 states “To expand access
to health care services, including sexual, reproductive, and maternal health services, for
immigrant women, men, and families by removing legal barriers to health insurance coverage,
and for other purposes” (H.R. H. R. 4240, 2014). I would like to propose additional
items to be added to this bill. First, would be to increase grant funding for academic-
community ventures that would provide care to migrant children regardless of their legal status.
Secondly to provide funding for nursing towards tuition, for those nurses who voluntarily work
in a clinic for a month each summer to provide care. These nurses would receive $5000 grant
money towards tuition the semester after doing their volunteer work.
Both the USCSD Mobile Dental Program and the Farm Worker Family Health Program’s
(FWFHP) went to where the population was located. While providing care, they researched the
characteristics of the population and their health needs (Mulligan et al., 2010 and Connor et al.,
2010). When advocating funding data needs to be provided to substantiate the need. My
proposal would include the current statistics for migrant children population and needs. I would
also follow the model provided by these two programs to work with university programs to
provide the volunteers to staff the program. In Powder Springs, there is a significant Hispanic
migrant population. There are also several nursing university programs that student nurses could
help to provide assessments and care. In following the example of going to where the population
is there is a flea market in the area that is attended every weekend by this population. The booths
rent for $12.00 per day. A booth could be rented to provide educational materials on where to
access care throughout the county. In the future with the appropriate organization, they could
offer immunizations to the children of the migrant workers.
Existing Laws Impact on Advocacy Efforts
The ACA is affecting migrant workers currently. Naturalized citizens have the same access as
U.S. born citizens. Lawfully present immigrants will have limited federal access.
Undocumented workers will not receive any access to health insurance or care except in an
emergency (National Immigration Center website, n.d.). There are many migrant workers who
do not understand they have access, or feel they do not have the income to pay for the insurance.
Public health can be affected by care not being given to this population; in GA there have been
outbreaks of tuberculosis at local schools (CBS 46 website, 2014).
How to influence Legislators – Three Legs of Lobbying
To make policy changes, the issue needs to be presented through the Three Legs of Lobbying.
The first leg is getting it represented at the Capitol level through lobbying. Working with other
lobbying organizations, writing one-page policy letters, and meeting with legislators, can do
accomplish working to get it addressed at the Capitol level (Amidei, n.d.). The second leg is the
grassroots activity that includes creating a website with alerts to notify subscribers, getting
legislators to visit your program, and to attend community meetings to talk about your issue. The
third leg is working with the media. It can be done by writing to the editor, creating articles for a
newsletter, and publishing national reports (Amidei, n.d.).
Hurdles in Legislative Process and Overcoming the Hurdles
A bill first needs to be drafted, and then it will be submitted to the House of
Representatives or Senate. Bills are then submitted to a committee, and in committee they can
become stuck or die. There will be competing lobbyist for and against the bill ("Barriers
legislation," 2011). Advocates are making a case attempting to pass a bill providing funding that
will include care to illegal migrants is very controversial. Current legislation is trying to be
created for immigration reform. To get over these barriers, it is important to have support from
other lobbying groups. Farm Workers Justice and United Farm Workers are two groups who
could be accessed to help advocate for these changes.
An ethical dilemma is should illegal migrants have the same right as U.S. citizens to health care.
Most Americans feel that human beings have a right to healthcare (Kovner & Knickman, 2011).
I believe it goes beyond if it is a right or not because the health of this population can affect other
U.S. citizens. The Guide to the Code of Ethics Provision Eight provides that a nurse should
promote the health of the community, the nation, and internationally. The migrant population is
part of the community ("ANA Ethics," 2010).
Nursing has an ethical responsibility to advocate patient’s needs. The migrant population,
especially the children, lack in access to care. A policy change could provide funding to student
nurses towards tuition if they volunteer their time caring for the population. It can be done
through academic-community joint ventures that should also receive additional funding. The
legislative process can be difficult, but by using the three legs of advocacy changes can be made.
2014 Clinical Quality Measures (CQMs) Adult Recommended Core Measures. (2014). Retrieved
Amidei, N. (n.d.). The three legs of successful advocacy. Retrieved from
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Code of Ethics for Nurses. (2010). Retrieved July 28, 2014, from http://www.nursingworld.org
Connor, A., Layne, L., & Thomisee, K. (2010, March). Providing care for migrant farm worker
families in their unique sociocultural context and environment. Journal of Transcultural
Nursing, 21(2), 159–166. doi: 10.1177/1043659609357631
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Healthy People 2020 website. (n.d.). http://www.healthypeople.gov/2020/
Kovner, A. R., & Knickman, J. R. (Eds.). (2011). Health care delivery in the United States
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transcript]. Retrieved from
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underserved migrant children. Journal of the California Dental Association, 38, 115-121.
Retrieved from http://www.cda.org/
National Center for Farmworker Health website. (2014). http://www.ncfh.org/
National Immigration Center website. (n.d.). http://www.nilc.org/
Peach, H. (2013, May 3). Migrant farm-workers and health. Rural and Remote Health, 13, 1-3.
Retrieved from http://www.rrh.org.au
The Affordable Care Act and Latinos. (2014). Retrieved from
The legislative Process. (2011). Retrieved from http://congress.indiana.edu/legislative-process
Waldeman, H. B., Cannella, D., & Perlman, S. P. (2010, November). Migrant farm workers and
their children. Exceptional Parent, 52-53. Retrieved from www.eparent.com
Infusion Center Chemotherapy Process Flow
Transforming Nursing & Healthcare Through Information Technology
July 27, 2014
Infusion Center Chemotherapy Process Flow
The Infusion Center at Cancer Treatment Centers of America (CTCA) Southeastern
administers 153,300-chemotherapy infusions each year, and additionally will administer
thousands of hydrations and blood products. The administration of chemotherapy protocols is
complex and has multiple possibilities for errors to be made (Neuss et al., 2013). Clinical
workflows define each step in a process in the clinical care of patients. It includes a series of
actions, who accomplishes them, and the sequence of the actions (Morgenstern, n.d.). The
purpose of this paper is to flowchart a clinical process and the use of technology, and to analyze
any needs for improvement.
The hospital opened in August 2012, and one year later after issues with patient wait times,
the workflow was assessed for possible changes. Patient wait times were averaging between two
and three hours. The first tool used was to interview the clinicians involved with the
chemotherapy process, and then the process was flow charted to look for defects (AHRQ Agency
for Healthcare Research and Quality, 2013).
Pre-Infusion Nursing Process
The pre-infusion process is displayed on pages one to two, and the infusion process on
pages three to five. Below is a list of acronyms for each of the Allscripts system abbreviations:
AMPFM – Access Manager/Patient Financial Manager
SCM – Sunrise Clinical Manager
SMM – Sunrise Medication Manager
ORM – Order Reconciliation Manager
ES – Enterprise Scheduler
On page one, the patient arrives at the outpatient clinic, and the unit secretary checks the patient
in through AMPFM, and the patient’s picture is taken to help the clinicians identify the patient.
The picture becomes part of the patient’s record in SCM in the Clinical Summary page. The
clinic nurse is notified that the patient is ready, and the clinic nurse escorts the patient to a clinic
exam room. Everything that the patient needs done in the clinic is done from the clinic room.
The patient does not move from the room, the clinicians scheduled to see the patient go to the
clinic room. Height and weight are obtained, to have the correct information for the physician to
base the chemotherapy dosing. Vital signs, assessment and the blood draw are completed. This
information is documented in the nursing outpatient clinic note in SCM. When the blood is
drawn, the patient’s armband is scanned and matched to the physician’s orders. Collection
manager receives this information from SCM and prints off all of the lab labels. These labels are
applied in the room to prevent mislabeling of specimens. The nurse updates the patient’s
medication history in the medication profile in SCM. The updated medications will go into the
ORM module for reconciliation by the physician. The nurse will create any nursing orders that
may be needed. The lab results the specimens in Sunquest lab system, and this interfaces into
the results tab in SCM for the physician’s review. The nurse notifies the physician that the
patient is ready to be seen.
Pre-Infusion Physician Process
Page two in the process flow focuses around the physician’s visit with the patient. Prior to
going into the patient’s room, reviews the patient’s lab results to prepare for discussing treatment
options with the patient. If the patient’s Hemoglobin (Hb) ≤11 g/dL or ≥2 g/dL below baseline,
the patient may need a transfusion prior chemotherapy (NCCN Guidelines Version 2.2015 Panel
Members Cancer- and Chemotherapy-Induced Anemia [NCCN Panel], 2014). The flow chart
shows the decision point for no; and the chemotherapy cannot be given, and treatment for anemia
will begin. Or the decision is yes, because the labs show the patient values are within range, and
they can proceed with chemotherapy. The physician will open the progress note, and pull the
labs into the note and notate they have reviewed the labs with the patient. Next the physician
will open ORM through the progress note and review the medications with the patient. The
physician will reconcile the medications, and make any prescription changes needed ("TJC
Patient Safety," 2014). The physician will review the previous chemotherapy administered to the
patient in the treatment summary in SCM. Patient should receive the same chemotherapy dosing
unless there are changes in the patient’s condition. The physician will now order the
chemotherapy protocol for the patient. The nurse now escorts the patient to scheduling to review
the schedule for the week. Schedulers will review with the patient in ES, and the patient can
come anytime during the next day, and scheduler will make changes based on the patient’s
needs. The patient will now proceed to the infusion center.
Pharmacy Infusion Process
The pharmacy verification work list in SMM is populated with patient chemotherapy orders
in less than ten seconds from orders entered by physician in SCM. During the time that patient
is with the scheduler, pharmacy will be verifying the chemotherapy orders and begin the
compounding. On page three, pharmacy finishes compounding the medications and updates the
infusion board with the information that the medications are ready for the patient’s infusion.
Chemotherapy Nursing Infusion Unit Process
The patient arrives in the waiting area for the infusion center, and the patient care technician
(PCT) checks them in on the infusion board. The PCT escorts the patient to an infusion chair,
and the location is updated in the infusion board. It allows the nurses to know where the patient
is located. The PCT will also perform and document the patient’s vital signs in the Vital Signs
flow sheet in SCM. The PCT then notifies the nurse educator that the patient has arrived.
The nurse educator provides chemo specific education to the patient and updates the Adult
Education and Outcomes flow sheet. After any questions have been answered, the nurse
educator brings up the chemotherapy consent form, and the nurse and patient sign the consent.
By creating the documentation, the infusion board is updated with the education being
The infusion nurse introduces himself or herself to the patient, and the nursing infusion
assessment is completed (page 4). Vital signs, labs, education, and consent are reviewed in
SCM. The nurse accesses the vascular access device (VAD), and checks for blood return. The
data is documented in the infusion flow sheet. The nurse picks up the chemotherapy from
pharmacy and at the patient chair side has a second registered nurse check the chemotherapy
against the orders. The chemotherapy is setup on a smart pump, and each medication is scanned
into the eMar for SCM. It will document the time the infusion was started for each drug in the
eMar and infusion flow sheet. The chemotherapy infusion will complete, and the smart pump
updates the infusion end times onto the eMar and infusion flow sheet. The infusion nurse will
discontinue the chemotherapy and de-access the VAD.
On page five, the infusion nurse escorts the patient to scheduling to review the schedule for
the week, and schedule the future chemotherapy visits in ES. The patient returns each day for
their scheduled chemotherapy until the current orders are completed. The infusion nurse will
now review medications with the patient and completes a discharge summary in SCM. The
discharge summary is reviewed with the patient, and the patient signs the online discharge
summary. The discharge summary is then printed and given to the patient. Patient will return
home until the next cycle of chemotherapy.
Quality Measure Evaluation
Patient satisfaction was related to how long they had to wait in the waiting room prior to
moving to an infusion chair. The current metric was not clearly defined, and time points within
the electronic health record (EHR) were reviewed to create a more precise time periods. A goal
was created to decrease the wait time to 45 minutes. When reviewing the process flow, it was
discovered that not all the functionality of the infusion board was being used. One area that can
help create a more accurate tracking time is the patient’s location will be tracked in the infusion
board. It will create an objective data, and can be reported from the system. In the flow chart, I
would add an additional task for the scheduler to change the location of the patient to clinic
discharge so that it can create a start time for the wait time. The second-time point would be
when the infusion nurse opens the infusion flow sheet, and the location and time will be updated
in the infusion board. The infusion board can create alerts when changes are made in the board.
By setting an alert when the patient location changes, or education is done, the appropriate
clinician can receive a page making them aware that the patient is ready for their next step in the
Workflow analysis is important because defects in the process can be viewed in the process
flow. The chemotherapy infusion process is one that defects could cause a decrease in revenue,
but more importantly a patient could be hurt (Morgenstern, n.d.). A review of the chemotherapy
infusion process was completed, and defects in the communication were found. The solution is
to increase the functionality of the infusion board technology to notify clinicians of each step.
The wait times can be reported on monthly to review if the solution is working.
AHRQ Agency for Healthcare Research and Quality. (2013). http://healthit.ahrq.gov/health-it-
Morgenstern, D. (n.d.). Clinical workflow analysis - Process defect identification [PowerPoint
slides]. Retrieved from
NCCN Guidelines Version 2.2015 Panel Members Cancer- and Chemotherapy-Induced Anemia.
(2014). Cancer -and chemotherapy - induced anemia. Retrieved from
National Patient Safety Goals Effective January 1, 2014. (2014). Retrieved from
Neuss, M. N., Polovich, M., McNiff, K., Esper, P., Gilmore, T. R., LeFebvre, K. B., Jacobson, J.
O. (2013, March). 2013 Updated American Society of Clinical Oncology/Oncology
Nursing Society Chemotherapy administration safety standards including standards for
the safe administration and management of oral chemotherapy [Supplemental material to
magazine]. Journal Of Oncology Practice, 5s-13s. doi: 10.1200/JOP.2013.000874
Identifying a Researchable Problem and Translating the Evidence Into Practice
NURS - 6052 – Section 46
Essentials of Evidence-based Practice
November 9, 2014
Identifying a Researchable Problem and Translating the Evidence Into Practice
Taking care of patients is more than just performing a variety of tasks, but should be
based on the most relevant evidence available, and patient preferences (Schaffer, Sandau, &
Diedrick, 2012). Nurses who are conducting research should do a literature review to analyze
the existing knowledge available (Polit & Beck, 2012). On October 1, 2015 the United States
will convert to ICD-CM 10 and it will increase the requirements for documentation in the
electronic health record (EHR). To meet the new requirements, facilities not only will need to
change their coding of patient charts, but physicians will need to be educated on the increased
requirements in the clinical record (Nichols, 2014). The research question to be developed
involves; will clinical documentation quality improve if education is provided by at clinical
documentation improvement practitioner (CDIP), and what is the difference in case mix (CMI)
and Patient Safety Indicator (PSI) (Battelle, 2011) if a concurrent versus retroactive review is
done? A review of the literature for existing evidence will be completed and synthesized for
information related to the PICOT question. The purpose of this paper is to identify a
researchable problem, review the literature for existing evidence, develop the PICOT question,
and develop a strategy to implement an evidence-based practice change.
Summary of Improving Documentation
The Center for Medicare Services (CMS) has created a new regulation to use ICD-10
diagnosis and procedures codes starting October 2015. It will involve increased documentation
on progress notes by physicians to be reimbursed (Nichols, 2014). The premise of this change is
to better document outcomes for patients, be able to benchmark data between hospitals, and
improve care of patients. The reimbursement for care will be based on how well the patient chart
is coded and documented (Kealey & Howie, 2013). The clinical documentation improvement
practitioner (CDIP) nurse will monitor the documentation, and educate the physician on their
clinical documentation so that it accurately demonstrates the intensity of service and level of care
provided for the patient (Brown, 2013).
Identification and Significance of the Problem
Poor clinical documentation by physicians will result in less reimbursement and a
decrease in quality care. The physician documenting a diagnosis such as heart failure must be
specific to the type of heart failure. Is it systolic or diastolic? The documentation within the
chart must be supportive of the diagnosis. The physician also must document any comorbidity
that is affecting the length of stay. The difference between poor, incomplete documentation can
be as much as $4000.00 less per patient visit (Hines & Yu, 2009). If the data is not accurate, it
also will effect the reporting on core measures. The issue is insufficient documentation will
result in poor quality measures reporting and decreased financial reimbursement.
Analysis of Five Questions
It is important to define well-worded questions for research to be able to answer the
clinical question (Polit & Beck, 2012). Questions can be quantitative where the data will be
calculable or qualitative that compares the meaning of an issue. The PICOT acronym is five
factors that can be used to form a research question (Polit & Beck, 2012). When brainstorming
possible questions it is necessary to figure out background questions from foreground questions.
Background questions may addresses parts of the issue, but research can answer foreground
questions. Below are five questions that I brainstormed to identify my PICOT question.
1. Why has the case mix index decreased over the last six months?
2. Would a concurrent review versus retrospective review improve the documentation?
3. Is it the physician or coders’ responsibility to assign an appropriate diagnosis code?
4. Does the documentation in the patient chart provide the data necessary for quality
5. Do the physicians need education on documentation in the patient’s chart? What is
the definition of appropriate documentation?
The issue is that the documentation is not supporting the quality indicators or financial
reimbursement. Each of the questions above is background questions, they each look at a piece
of the issue but would not be complete enough to answer the clinical question.
Once the problem is identified for research, the researcher must decide if it is feasible to
research the problem. The following areas must be reviewed, although they may not be
necessary for every research study; time, participant availability, cooperation of others,
equipment, facilities, money, and ability of the researcher (Polit & Beck, 2012). Facilities and
providers will be forced into the ICD-10 changes on October 1, 2015. To provide evidence-
based change in the facility, it is necessary to create a research plan that would take place over
six months. The facility is willing to cooperate with the research plan, and minimal funding will
be needed. Two units will be identified to be part of the study, one will be a control group that
will not have a CDIP assigned to the unit, and the other unit will have a CDIP to educate the
physicians. The participants will be the hospitalists that are assigned to each unit, and the units
selected each uses a different group of hospitalist (Polit & Beck, 2012). The researcher is a
certified CDIP, who has passed their certification exam through the American Health
Information Management Association (AHIMA) (American Health Information Management
Association [AHIMA], n.d.). The current electronic health record (EHR) will be used for the
chart reviews, and the facility will grant the researcher access to the EHR.
The five variables for PICOT questions are population, intervention or issue, comparison,
outcome, and time (Riva, Malik, Burnie, Endicott, & Busse, 2012). The five variables for the
PICOT question are:
P – The population that will be studied is the hospital inpatients. CMS has
defined this as the population that core measures will be reported, and payment is
based on DRGS.
I – The issue of insufficient documentation will cause a decrease in
reimbursement, accurate quality reporting, and decline in patient care. When
documentation is vague, incomplete, or unreadable it prevents accurate
communication between the physician and nurse (Russo, 2012).
C – The comparison of concurrent reviews versus retrospective reviews to prove
that by providing reviews during the patient’s hospitalization will improve the
O – These indicators; an increase in case mix index, increased complex
comorbidity, and patient safety indicator expected decrease versus observed,
measure the quality of documentation through these outcomes.
T – The data for the outcomes will be reviewed after six months to measure if the
improvement through education has improved the outcomes.
The construction of the PICOT question provides a framework for the researchers as they
develop their plan for researching the issue. It is important to take time to develop the question
so that researchers and future readers of the findings will be able to understand the issue. The
selection of a specific population, issue, outcomes, and time frame will assist the researcher in
making sure the PICOT question, is an answerable question (Carman et al., 2013). The PICOT
question is: Education provided by a clinical documentation improvement practitioner (CDIP)
will improve clinical documentation quality as evidenced by an increase in case mix (CMI) and
Patient Safety Indicator (PSI) (Battelle, 2011) if a concurrent versus retroactive review is done.
The evidence hierarchy has seven levels with the top level being the best evidence
available. The purpose of keywords is to find the best evidence research articles (Polit & Beck,
2012). The keywords selected to use for this search are patient safety indicator, CMS core
measures, clinical documentation, outcomes, patient outcomes, electronic health record, case mix
index, CDIP or CDIS, concurrent review, retrospective review. Each of these keywords, when
searched in the database, can map to subject headings that can expand the number of hits when
searching (Polit & Beck, 2012). Some of these words are also within the PICOT question and
are the significant ideas that will be searched.
The writer completed a review of five studies that were done related to quality of
documentation, clinical improvement documentation specialist, and case mix. The first study
reviewed is Patient safety strategies targets at diagnostic errors (McDonald, Matesic,
Contopoulos-loannidis, Lonhart, & Schmidt, 2013). The study is a systematic review, and the
authors identified 109 articles that met their criteria. The purpose of the study was to review
charts to see if the patient safety indicator (PSI) could be used to identify interventions that could
be used to correct missed or incorrect diagnosis. Through the review of the literature, they found
eleven interventions that could be used to diagnosis the patient more appropriately. A synthesis
of the data was difficult because of the various study designs in the literature. It was found that
this was a good basis to do further research on specific interventions (McDonald et al., 2013). It
is important to have an accurate diagnosis on the chart to provide care appropriate to the
diagnosis, and an incorrect diagnosis can be used in malpractice suits. The article applies to the
PICOT question the writer developed.
Michalak, (2011) conducted a review of medical records charting by physicians and
statistical forms to see if the International Classification of Disease (ICD) 10 were the same, and
if the documentation supported the diagnosis. He found there were a high level of being
complete, accuracy, and validity (Michalak, 2011). The study is important to verify that the
diagnosis is correct based on the documentation reviewed by a physician reviewer, but unlike the
previous study it does not directly support the writer’s PICOT question. It does speak to the
ability of the physicians to correctly document the patient diagnosis.
The next study, Validity of AHRQ patient safety indicators derived from ICD-10 hospital
discharge abstract data (chart review study) (Quan et al., 2013), combines the review of the PSI
and the quality of the documentation in the chart. The purpose of the study is to verify that the
PSI on the discharge abstract matches to the documentation in the record. It is the first study to
be done to validate the ICD-10 data. They were able to validate 5 out of 20 PSI, and the chart
documentation was used to validate. If the information was missing from the chart, the PSI was
not validated (Quan et al., 2013). The information in the study is important to the writer’s
PICOT question; because it shows improved documentation does validate the observed PSI to
the expected decrease in the PSI.
Stacy, Washington, Vuckovich, & Bhatia, (2014) created a study to review the effects of
implementing a new electronic health system (EHR), and clinical documentation improvement
specialist educating physician would improve the documentation. The improvement was
measured by an increase in the case mix index (CMI) (Stacy, et al, 2014). The writer’s PICOT
question is directly related to information in this study. The findings from the study showed an
insignificant increase in the CMI, but there is a dependence on the type of services that the
hospital provides to patients. The increase was from 1.65 to 1.68, which seems insignificant, but
makes a big difference in the amount of reimbursement (Stacy et al., 2014).
The last study, Improving and measuring inpatient documentation of medical care within
the MS_DRG system: Education, monitoring, and normalized case mix index (Rosenbaum et al.,
2014), reviewed the neurology service to see if by educating the physicians could they show an
improvement in documentation based on the case mix index (CMI). The physicians showed an
improvement in the documentation by working directly with the clinical documentation
improvement specialist (Rosenbaum et al., 2014). It directly supports the writer’s PICOT
Additional research uncovered a recently published study, Improving physician clinical
documentation quality: Evaluating two self-efficacy-based training programs (Russo,
Fitzgerald, Fuchs, & Redmon, 2013) was reviewed. An education program was provided to
residents at an academic medical center. The results of the study showed that residents who
completed a structured education program had an increase in the quality of their documentation.
A video presentation, ICD-10 and Clinical Documentation (Nichols, 2014), developed by
Medscape with support from the Centers for Medicare & Medicaid Services reviews the
requirements of documentation once ICD-10 is implemented on October 1, 2015.
Review of Literature Finding and PICOT Question
The first three studies have findings that can be supportive to the writer’s research
question. They each speak to the quality of the medical record documentation. The last two
studies both have an experiment to review the quality of the record based on improved case mix
index (CMI). They review the CMI on charts prior to education of the physicians. Then they
use the clinical documentation improvement specialist to educate the physician on
documentation in the record that supports the diagnosis. Both of these studies can be used to
support the writer’s PICOT question. The video by Dr. Nichols provides the basis for the
facility to make the changes for ICD-10. Russo et al. (2014) recently published an article that
provides the educational content based on their research that can be used by the CDIP during the
Nursing Practice Supported By Evidence
Nurses are leaders in quality departments of hospitals and assist in education of quality
initiatives to all clinical staff. They have a role in the multidisciplinary team to influence quality
and safety issues (Richardson & Storr, 2010). Nurses have been involved as a case manager, and
physicians are accustomed to their review and questions. Rice Memorial Hospital published a
case study of the transition of case manager nurses to clinical documentation improvement
specialist (CDIS). The CDIS “reviewing an average house census of approximately 42 charts
each. Including six to ten admissions per day. Taking on the expanded role meant reviewing
every chart for present-on-admission (POA) conditions, admission and ongoing medical
necessity, and adherence to core measures for quality while also looking for documentation
improvement opportunities” (Hinderks, Vagle, & Wolf, 2014, p. 102).
The role of the clinical documentation improvement practitioner (CDIP) involves the use
of their clinical knowledge to review charts for the lack of documentation about the patient. The
CDIP reviews the chart concurrently to educate the patient, and make immediate changes. These
changes can make a difference in the case mix index (Stacy et al., 2014). The increase in the
case mix index creates better reimbursement for the facility to provide the appropriate amount of
care. The addition of a chronic diagnosis can increase the length of stay for a patient, the
appropriate documentation of that diagnosis will increase the reimbursement, and the hospital
has the resources for that patient to stay the additional days (Nichols, 2014). The CDIP
reviewing the chart will focus based on the diagnosis of the patient and check to see if all clinical
tests appropriate to facilitating the care are ordered on the chart. It also supports the medical
diagnosis of the patient (McDonald et al., 2013).
Clinical Documentation Improvement Affect On Outcomes
Quality documentation involves being specific about what is going on with the patient. It
means to specify where a wound is located, how does it appear, and does it have drainage. The
communication of this information to a multidisciplinary team allows that to treat a patient with
the interventions that will increase healing (Nichols, 2014). McDonald et al., (2013) found
eleven interventions that could be used by a CDIP to review the chart and assure a correct
medical diagnosis. The reviews of the interventions are related to patient safety indicators, and
the documentation could provide an increase in patient safety (McDonald et al., 2013). The
reverse is true when there is a lack of quality documentation. The CDIP role educates the
physician on specific issues on current patient’s charts, and the additional documentation
prevents a patient from being discharged too soon, or not getting treatment for any diagnosis that
are not charted. The case mix index and patient safety indicators can be tracked for each
physician, allowing the hospital to look for trends for physician education (Rosenbaum et al.,
2014). These can be tracked in the quality improvement program to make changes to care
Strategy For Implementing Clinical Documentation Improvement
The goal for healthcare organizations is to improve patient outcomes, and maximize
reimbursement for the care provided. The purpose of the researching the use of clinical
documentation improvement practitioners (CDIP) on one unit and having a control unit, is to be
able to demonstrate to the executive team, physicians, and nursing teams the effectiveness of the
CDIP program. A presentation of the evidence-based practice would be presented to key leaders
in the facility; the executive team, chief medical officers, and nursing leadership to receive
executive backing of the plan. It is important to have support from the top when implementing a
new quality improvement program (Larkin, 2012).
The next step would be to provide lunch and learns on each of the units in the hospital, and
invite the multidisciplinary team working on the unit to attend. An overview of the new
program, and the impact on patient outcomes would be presented. It is important during this
presentation to explain how this would change any current processes on the unit and answer any
questions from the staff. It is important to create a common vision between nursing and
physicians on complete and accurate charting on the front end will make a positive impact
patient care and reimbursement (Hinderks et al., 2014). Education will need to provide to all
physician groups that practice within the hospital. To help with gaining their support, education
can be provided at the hospital and at each physician practice. If the physicians understand that
this is to assist them in their practice, not take away from their time with patients, and be allowed
to provide feedback, they will participate in the program (Byrnes & Fifer, 2010). Most
opposition to change comes from not understanding the positive impact for the patient outcomes,
and feeling it is one more regulatory requirement. Byrnes and Fifer (2010) state, “projects that
improve quality, decrease complications, decrease mortality, and improve patient functional
status. Goals such as these will motivate physicians” (Byrnes & Fifer, 2010, p. 87). The clinical
documentation improvement program would work hand in hand with the financial department to
use predictive modeling further to create a case for making the change. ICD-9 data and claims
from the previous year can be used to show the level of impact that the CDIP can have on the
reimbursement. A review of the documentation associated with the claims would show the
deficiencies in the documentation further to support the case for implementation (Hinderks et al.,
The education of physicians and clinical staff communicates to them the change and
begins the process of implementation. During this time, the new CDIP will receive education
from the certified CDIP directing the program, and receive a boot camp on taking the
certification exam through AHIMA (Hinderks et al., 2014). The new department will work
together to create physician queries to address the most common medical diagnosis. Process
flows will be created to guide everyone though the new work processes. Physicians will be
reviewed for the most common diagnosis’s used by the physician, and for their baseline case mix
index. A monthly education program will be offered for the physicians at the medical executive
team meeting. The education will be modeled after the research done by Russo et al., (2014)
using physician champion examples of quality documentation by diagnosis (Russo et al., 2013).
The CDIP will report to their assigned units the first week of July 2015, and allow for the CDIP
and physicians to work collaboratively prior to the October 1, 2015 implementation of ICD-10.
The formation of an answerable research question will be effectual in finding an answer
to a clinical issue. The development of the research plan will depend on formatting a PICOT
question to provide a structure for searching for evidence-based practice articles (Riva et al.,
2012). A literature review was completed with a compilation of the information for data that
would support the writer’s PICOT question. Two of the five studies give direct support to the
question. Additional research resulted in finding an article on providing evidence-based
education, and it showed an increase in the quality of the documentation (Russo et al., 2013).
Based on this information, a research plan was created based on the PICOT question: Education
provided by a clinical documentation improvement practitioner (CDIP) will improve clinical
documentation quality as evidenced by an increase in case mix (CMI) and Patient Safety
Indicator (PSI) (Battelle, 2011) if a concurrent versus retroactive review is done. The research
plan will be implemented over a six-month-time period by the certified CDIP to test the
hypothesis. Based on the results, the facility can move on with the implementation of the CDIP
program, or make adjustments to increase the success of preparation for ICD-10 on October 1,
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Planned Change in a Department
Interprofessional Organization and Systems Leadership
NURS - 6053 - 18
October 5, 2014
Planned Change in a Department
To Err is Human: Building a safer health system reports that medication errors are
occurring frequently, even with technology in place to make medication administration safer
(Committee on quality of health care in America [IOM Committee], 1999). Nursing leaders
have a responsibility to lead changes within a department or across departments. The purpose of
this paper is to review the issue in a department, describe how to change practice to meet facility
mission, vision, values, and professional standards. Describe how to facilitate the change using a
change model, and the stakeholders who should be involved.
Problem in the Department
The patient had stopped the nurse before the chemotherapy was administered, to let the
nurse know that this was not the chemotherapy she should receive. A review was done based on
this episode for the number of chemotherapy errors in the last six months. Chemotherapy
administration involves intricate protocols with high-risk medications. The size of the error can
determine how harmful it could be to the patient. Even a small error could cause renal damage
(Vioral & Kennihan, 2012). The risk management department completed the review, and they
found an average of 30 chemotherapy errors per month. The errors were primarily wrong drug
and wrong dose.
Specific Change to Practice
The policy at the hospital stated that two nurses had to verify the “Five Rights” of
medication administration at the patient bedside. The American Society of Clinical Oncology
(ASCO) and Oncology Nurse Society (ONS) standards state “A practitioner who is
administering the chemotherapy confirms with the patient his/her planned treatment prior to each
cycle and at least two practitioners or personnel approved by the practice/institution to prepare or
administer chemotherapy, verify the accuracy of: drug name, drug dose, drug volume, rate of
administration, Expiration dates/times, if applicable; expiration date/time is not required if for
immediate use (Immediate use must be defined by intuitional policy, state, federal regulations,
eg, use within 2 h), and appearance and physical integrity of the drugs”(Neuss et al., 2013, p.
A review of the workflow showed that many times the nurses were busy, and they were not
physically reviewing the chemotherapy with another nurse against the orders. In passing they
would verbalize what chemotherapy they were going to administer or check it prior to the patient
arrival, and they were not verifying with the patient. All of the chemotherapies were delivered
by pharmacy in the “chemotherapy bucket” with all the protocol medications in the bucket. The
change that was implemented was the establishment of a new role for nursing, the chemotherapy
processor. To meet the standards for chemotherapy administration, it was decided one nurse
would be dedicate to verifying the chemotherapy with all other infusion nurses.
Two outcome measures were identified and put into place in December 2013. Because the
chemotherapy processor was a new role, it was decided that the number of near misses would be
recorded that were caught by the chemotherapy processor. This data would support the creation
of the new role. The second outcome was the number of chemotherapy errors per month, and the
objective would be to decrease to zero errors over a three-month-time frame.
Alignment with Mission, Vision, Values, and Professional Standards
The mission, vision, and values are summarized in the statement that the facility provides
“The Mother Standard of Care” (Cancer Treatment Centers of America website, n.d.). The
chemotherapy nurse understands that you would verify and administer the chemotherapy as if it
was your mother sitting in the infusion care. The ASCO/ONS chemotherapy standards will be
met by having the chemotherapy processor nurse be the second verifier with each nurse
administering the chemotherapy, and with the patient at the bedside (Neuss et al., 2013). Finally
the Nursing Code of Ethics Provision 3 states, “the nurse promotes, advocates for, and strives to
protect the health, safety, and rights of the patient” ("ANA Ethics," 2010, provision 3). The
chemotherapy processor nurse and infusion nurse by following the standards will be protecting
the health and safety of the patient.
Change Model and the Steps to Facilitate Change in the Department
The hospital decided a change was needed, and a project team was assembled. The team
followed the Stages of Change Model, which is an adaptation of the Lewin's three-step change
process. There are five steps in the change model; precontemplation, contemplation, preparation,
action, and maintenance (Marquis & Huston, 2012). Precontemplation is the stage when there is
no current intention to make a change, until the patient identified the error about to be made in
administering the chemotherapy; there was no change contemplated. In the next stage project
team decided to review the errors and contemplated if there was a practice change needed, or
was it a discipline issue. Even if individual nurses were disciplined, the team decided there still
could be issues because of the busy unit they were on. The third stage is the preparation, and the
team developed a plan for making a change. It included creating the new role of the
chemotherapy processor. Education was given to the current nursing staff on how the new role
of the chemotherapy processor would work with them. The nurse manager got approval to a
chemotherapy nurse for the role of the chemotherapy processor, and nurse was hired. It
completed the action stage. The maintenance stage is the actions taken to prevent a relapse into
having chemotherapy errors.
The project team set up two outcomes to measure the change. First were the number of
near misses caught by the chemotherapy processor and the number of errors each month. This
change model was chosen, because it breaks the process of change into manageable steps. It also
gives time to make a planned change, and for the stakeholders to get used to the idea of change
(Marquis & Huston, 2012).
Stakeholders Needed for Initiating and Managing Change
The project team was made up of a multidisciplinary team. The process of chemotherapy
treatment involves the following disciplines; medical oncologist, pharmacist, infusion nurse, and
education nurse. In the ASCO/ONS chemotherapy standards each of these disciplines has a
specific responsibility to perform (Neuss et al., 2013), and the decision was made to include a
representative from each area. The director of clinical informatics had reported the data to
administration and was made the facilitator of the group. The director of quality and risk
management rounded out the team since they are responsible for quality and safety standards.
The facilitator leading this effort needed to be able to work with all of the stakeholders
from each department and to be objective about each departments input into the project.
Communication skills are critical to the success of the group. The leader must be able to
communicate the mission, vision, and values to the team members so they understand how the
goals of the project will meet each of them. The leader also needs to communicate the progress
of the team and the results throughout the organization (Marquis & Huston, 2012). The leader
uses their communication skills to facilitate the participation of all team members.
A patient knowledgeable about their chemotherapy protocol stopped the nurse from
making a medication error that could have created harm to the patient. It instigated a review of
the chemotherapy errors made over the last six months, which average 30 errors per month. The
hospital initiated a project team using the model, Stages of Change, to acknowledge the need to
change, plan for the change, take action to make the change, and to audit to maintain the change
(Marquis & Huston, 2012). The result was the creation of a new nursing role, chemotherapy
processor, and the decrease of chemotherapy errors to zero in three months.
Committee on quality of health care in America. (1999). To err is human: Building a safer health
system [Issue brief]. Retrieved from Institute of Medicine website: http://www.iom.edu
Cancer Treatment Centers of America website. (n.d.). http://www.cancercenter.com
Code of Ethics for Nurses. (2010). Retrieved September 21, 2014, from
Marquis, B. I., & Huston, C. J. (2012). Leadership Roles and Management Functions in Nursing
(7th ed.). Philadelphia, PA: Wolters Kluwer Lippincott Williams & Wilkins.
Neuss, M. N., Polovich, M., McNiff, K., Espir, P., Gilmore, T. R., LeFebvre, K. B., ... Jacobson,
J. O. (2013, March). 2013 Updated American Society of Clinical Oncology/Oncology
Nursing Society Chemotherapy Administration Safety Standards including standards for
the safe administration and management of oral chemotherapy. JOURNAL OF
ONCOLOGY PRACTICE, 9(2s), 5s-13s. doi: 10.1200/JOP.2013.000874
Vioral, A. N., & Kennihan, H. K. (2012, December). Implementation of the American Society of
Clinical Oncology and Oncology Nursing Society Chemotherapy Safety Standards: A
multidisciplinary approach. Clinical Journal of Oncology Nursing, 16, E226-E230. doi:
Design Considerations and Workarounds
Informatics in Nursing and Healthcare
NURS - 6401 - 3
January 11, 2015
Design Considerations and Workarounds
In 1999, the Institute of Medicine (IOM) released recommendations for patient safety and
estimating that there are over 7000 patient deaths per year from medication errors (Richardson,
Bromirski, & Hayden, 2012). One response to preventing these errors is the use of bar-coding
medication administration. The ordering, filling, and administration of medications are a
complex multi-disciplinary process, and the process can result in medication errors. The use of
technology could add extra complexity if not implemented correctly. Burke-Bebee, Wilson and
Buckley (2012) asked the question “They May Come But Will They Use It” (Burke-Bebee,
Wilson, & Buckley, 2012, p. 547). Implementing the use of new technology such as bar-coding
medication administration could also be affected by the use of clinicians. The study was done on
implementing technology to assure patients took their patients at home, but the issue became the
clinical staff did not adopt the new technology. Lessons from this study show that engaging staff
and ongoing education of imperative to the implementation of new technology (Burke-Bebee et
al., 2012). It is the same issue that can happen with bar-coding medication administration
(BCMA) design and implementation. The purpose of this paper is to review design
considerations to improve patient safety, what workarounds may be used by staff and should
those workarounds be mitigated.
Part I: Design Considerations
It is important for the nurse informaticist (NI) when considering a new system, to
consider if the design meets the business needs of the end user (Coronel, Morris, & Rob, 2013).
There should be a balance between hardware, software, and human factors during the design and
the implementation of a BCMA system to be successful. One of the ways to assure a correct
choice of systems is to have a demonstration to the clinical end users as part of the selection
process (Laureate Education, 2012h). Clinical end users need to understand the IOM report and
why BCMA is important. The nurse informaticist educates the clinical end users to the benefits
of using a bar-coding medication administration system and how it can impact patient safety.
Clinical end users, who understand the rationale behind implementing a new technology such as
BCMA, will have a better understanding when making decision about design and
The appropriate hardware can make or break an implementation of bar-coding medication
administration (BCMA). The nurse informaticist (NI) should work with the clinical staff and
do an analysis of the workflow and how various hardware devices will work in the environment
(Richardson et al., 2012). For example, a previous facility the information system department
chose a bar code scanner that had a cord on it without any input gathered from the end users. It
was tethered to the computer that had the software application on it. The problem with this was
that the nurse had difficulty reaching the patient to scan the armband due to all of the equipment
in the room and around the patient. The tethered scanners were replaced with a Bluetooth
scanner that provided the nurse freedom to move around the room and reach the patient.
Another factor contributing to the success of the implementation is the armband with the barcode
displayed on it. Testing by the NI and the end users needs to take place prior to implementation.
Because it will assure that the printer used to print the armbands, prints the barcode correctly and
the scanner can scan it without any issues (Richardson et al., 2012). Additionally the armband
printer should be unavailable to nursing, or they may print an extra armband. Each of these
hardware factors can impact patient safety. Because staff bypass scanning of the armband or
even the medication and potentially causes a patient medication error. Nurses become frustrated
trying to follow the guidelines, when the hardware issues make it awkward to follow the process.
The Joint Commission National Patient Safety Goals (JCNPSG) were published
originally in 2010, and updated in 2014 (The Joint Commission, 2014). Nursing informaticist
should explicitly use these goals when evaluating BCMA software. The first objective is to
improve the accuracy of patient identification, and prevent wrong patient errors in all areas of
treatment. “Acceptable identifiers may be the individual’s name, an assigned identification
number, telephone number, or other person-specific identifier” (The Joint Commission, 2014, p.
1). The second goal is to reduce harm associated with clinical decision support alerts. “Clinical
alarm systems are intended to alert caregivers of potential patient problems, but if they are not
properly managed, they can compromise patient safety” (The Joint Commission, 2014, p. 7).
The NI should work with clinical staff to determine selection criteria for selecting the software.
One criterion should be that the patient armband is scanned and that it will include at least two
patient identifiers to meet the JCNPSG Goal 1. A second criterion is that the alerts generated
when scanning the medication orders should be configurable based on JCNPSG Goal 6.
Otherwise, this configuration, can lead to workarounds that will have to be addressed (The Joint
Commission, 2014). Software applications may have two types of medication administration
records. Education of the staff is necessary to know when to use the electronic medication
administration record (eMAR) and a BCMA medication administration record (BCMA MAR).
The BCMA MAR should be configurable to view drugs based on the shifts worked by the
nursing staff, allowing the ability to look back or forward for medications on the schedule
(Grissinger & Mandrack, 2011). The inability of staff, to view the drugs that were administered
or are due in the future could result in missed doses of medications.
For a successful implementation, clinical staff using the new system should be involved in
all phases of the process from selection of a system to the testing of the system (Saba &
McCormick, 2011). The NI should have good change management skills to work with the
clinical staff and to increase the adoption rate of the new system. The NI can use
transformational leadership skills to focus staff on the vision and to assist the staff in ownership
of the new process (Glenn, 2010). Process flows of the current and future state created by the
NI, are used by the staff to follow during the implementation (Richardson et al., 2012).
Informatics Response to Insure Patient Safety and Quality
The implementation of a new software system should the System Life Cycle which
includes; initiate, analyze, design, implement, support continuous improvement (Saba &
McCormick, 2011). During the implementation phase, the NI must focus on two areas to insure
patient safety and quality. The first area, the NI focuses on is testing of the system prior to the
go live date for the system. During unit testing, the NI uses their clinical expertise to write test
scripts with the end users. During testing, the end users follow normal workflow process to
validate the utilization of the system for a typical day. Issues found during testing can be logged
and corrected prior to implementation. The facility should setup a testing area, could be a
training room, which has the same hardware laptop and scanner that the nurse will use at the
bedside. The use of a virtual environment will allow the NI to find software and hardware issues
that could impact patient safety and have them corrected (Saba & McCormick, 2011).
Pharmacist, physicians, and nursing should be involved to evaluate the use of alerts in the
system. To follow the Joint Commission National Safety Goal 6, each of these disciplines
should be involved in the implementation committee. During the implementation, the committee
evaluates the alerts to assure they are appropriate, and not causing any clinician to bypass alerts
(The Joint Commission, 2014).
The second area which the NI can make a difference is in the education of clinical staff
prior to implementation (Richardson et al., 2012). Support from senior nursing leadership should
allow the nursing staff to have adequate time for training. Training can be setup in a training
room with a virtual environment, training patient armbands, and medications with bar codes
available for the nurse to practice. They can be given time to walk through BCMA as many
often as necessary to obtain a comfort level. The NI that will understand the process, and
functionality of using the new system should train super users. A quality evaluation matrix
should be created to identify improvement to the medication administration by using BCMA. It
also should identify defects for the design team to correct in the system (Richardson et al., 2012).
Each of these measures can prevent patient safety issues, and measure quality based on using the
Part II: Employee Workarounds
Employees create workarounds in every area of business including healthcare. Even
when the NI addresses hardware, software, and human factors during the design stage, humans
seem to find a way to use information systems or not use them by finding workarounds.
Benefits and Consequences of Workarounds
The advantages of workarounds are that it’s hard to foresee every situation that a nurse
may encounter administrating medications. For example, the patient is coding on the floor and
saving the patient’s life drugs are administered under a physician’s direct order in the room.
There is not time for the order to be placed in the system, verified by pharmacy, and then
scanned by the nurse. Nurses remove the medications from a crash cart during a code. It should
be the exception and not the rule because workarounds can cause inefficiencies and patient safety
issues. For example, nurses may pour medications ahead of time, and print a patient armband to
keep near the automated dispensing device. They will scan the medication, and it appears as if it
was given on time. The nurse following this situation, may not be aware that the drug was given
two hours late, and administering the patient’s next dose may create an overdose situation (Saba
& McCormick, 2011). The scanning of the patient’s armband is to assure that the right patient is
receiving the right dose. When a nurse types in the patient’s identification number into the
system to bypass scanning the patient’s armband is in violation of the Joint Commission National
Patient Safety goal I (The Joint Commission, 2014).
Mitigating Workarounds or Not
The norm should be to not mitigate workarounds. The NI should make regular rounds on
the nursing floors to review for possible workarounds. It is not always the nurse who creates the
workaround out of laziness; there are times when scanners break, and it is not reported causing
the nurse to find a workaround. Or it may be there is a patient situation, such as a code that
forces the nurse to create a workaround. But overall using BCMA correctly has been found to
decrease medication errors by 54%. Creating workarounds causes medication administration
errors by overriding of alerts (Saba & McCormick, 2011). The PACU nurse was waiting the
patient to return from a late surgery, she anticipated that the patient would come back and
prepared the epidural pain medication order. She pulled the medicine from the automated
dispensing unit and hung the drug. When the patient arrived, she connected the medication to
the patient; the only thing not done was starting the drug. The patient was moved quickly to the
surgical floor, and the floor nurse asked if the PACU nurse had scanned the epidural prior to
hanging the drug, and the response was “no”. The floor nurse scanned the medication and found
that intravenous patient control analgesia bag was attached instead of an epidural bag. The
scanning of the medication prevented a medication error for the patient.
The use of BCMA will assist nursing in the prevention of medication errors and to meet
the Joint Commission National Patient Safety Goals. The NI functions to help in the selection of
the appropriate hardware, software, and foresees any human factors during the implementation.
To assure patient safety and quality, the NI can setup quality evaluations to show improvement
in medication administration errors and to also find areas that the system may need refining. The
use of BCMA should involve continuous quality initiatives to review for workarounds, and
prevent medication risks to the patient.