IPOC - Puget Sound Nursing Informatics (PSNI)

Holly Bowles RN, BSN, Clinical Informatics Specialist
Opened in 1960
281 Bed Community Hospital in North Seattle
with Level 4 ED/Trauma, Level 2 Neonatal
1900 Employees, 725 Medical Staff
◦ 34,000 ED Visits
◦ 1300 Births
◦ 11,300 Admissions
◦ 450,547 Outpatient Visits
2013 Statistics
Streamline work and be helpful in patient care
Reduce redundancies in documentation
Ease of use and maintenance of the POC
Care coordination: Interdisciplinary
Studies have shown that an interdisciplinary approach to care can assist in
reducing readmissions, mortality, costs and length of stay while
simultaneously increasing communication, collaboration and satisfaction
of care providers and patients (Preen et al., 2005) (Vazirani, Hays, Shapiro,
& Cowan, 2005).
Tool to manage complex patients across multiple
Must be evidence-based
Previous process was done on paper
Little interdisciplinary involvement. Plan of
Care on the chart was primarily nursing
Protocol based system with pre-printed
content. Had the ability to add additional
information/variances if needed.
Interdisciplinary group of clinicians:
◦ Included representatives from Nursing , RT, PT, OT,
Speech, Care Management, Food & Nutrition and
Pharmacy. Nursing’s members included Clinical
Nurse Specialists, Clinical Coordinators, Staff
Nurses and Managers.
Many meetings and serious work, 2009-2013
Hiatus for CPOE Implementation
Early Meetings (2009)
◦ Encouragement to think outside of the box
◦ Hospital was diagnosis-based
◦ Evaluated top ICD-9 codes and DRGs and
concluded that it was too large of a number of
IPOCs that would be needed
◦ Reviewed NIC/NOC content
 Used Specialty break downs to help focus the needs
◦ Reviewed Zynx Plans
◦ Decision to proceed with problem-based IPOCs
Meetings (2013)
Started in December 2012
Reviewed improved Zynx Plans of Care
Reviewed design decisions made in 2009
Reviewed list of requested Plans of Care from 2009
 Narrowed list down from 135 to 77
◦ Held 3 all day design sessions over 1 month along
with “homework” for designated staff
 Hospital wide IPOCs done with entire group
 Specialty based IPOCs done individually/small groups
Interdisciplinary- Therapies, Respiratory Care, Food &
Nutrition, Pharmacy, Care Management, Nursing
Problem-based pans
Easy access to review, initiate and update
Evidence based standards using Zynx
Standardized Language: SnoMed CT
Protocols are incorporated
Clinical Notes are associated with Expected Outcomes
Unique Clinical Summary Layout to facilitate both
staff and provider usage
Easier to focus attention on the highest priorities for
the patient during this encounter
Sample IPOC
Clinical Summary Layout
Taking us where no Northwest Hospital Staff
has gone before…..
Can you tell if this patient is progressing
toward Expected Outcomes?
We see some of what the staff did during this shift, but
not where the patient is related to their goals….
 Documented
in Shift Assessment
 Documented in MAK
 Documented in VS/I&O
 What does this mean???
Progress toward or away from Expected
Unusual event note- Security issues, family
issues, lost belongings
Emergent Codes
ADT notes
Chart by exception
Don’t duplicate charting already done
Ask: Should this be captured as a problem?
Writing a good Clinical Note is a skill
which takes thought and practice but it will
save time in the long run and our communications
will be much improved !
One Giant Step…
If NWH policy states that we are a
“Documentation by exception system”,
Then, we don’t have to do
“what we have always done,”
So, let’s take back the clock!
It is time to leverage the power of technology to
improve the quality of care we are providing for
our patients!
Workflow Engine listens for clinical assessment
documentation, lab test results and signed orders, then
suggests patient problems based on clinical data entered in
The workflow listens for the initial plan of care save, then
sends an alert to the nurse four hours after patient
admission, with a reminder to complete the Plan of Care, if
not already done.
The workflow monitors for completion of daily Plan of Care
Review documentation, and sends a reminder to complete the
Plan of Care Review, if not already documented.
After patients are discharged the workflow resolves all active
Plan of Care problems.
Training Sessions: 4 hrs. for RNs, 1.5 hrs. for Therapies
Training included “hearts & minds” intro, Plan of Care: create/manage,
Clinical Notes, Practice.
IPOC Tip Sheet developed at the end of 1st week of post-LIVE support
Training Objectives:
 Navigate established Plans of Care
 Manage suggested problems
 Demonstrate how to develop a Plan of Care, select and add interventions
and chart to outcomes
 Use predefined evidence-based Plans of Care to individualize patient
 Document a clinical note
 View Standards (original Plan of Care template)
 View Plan of Care elements and Clinical Notes in Clinical Summary
 Note: although they work together, Problems, Expected Outcomes and
Interventions are managed separately.
Advertising began with the Clinical Support
Team talking with staff during rounds
Flyers posted throughout the units
“Treats” with labels speaking of Plan of Care
distributed to all clinical staff
Staff Meetings
Weekly Announcements
Staff embraced the IPOCs/Clinical Notes on the first
day. The staged roll out planned for 4 days was done
in 2! Couldn’t stop them!
Staff became more aware of what they were
documenting and questioned processes to stream
line their documentation
Staff have commented on time saved, ease of use and
how it has brought meaning to the plan of care
Providers became aware of the IPOCs and asked great

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