Computerization: one facility's road to success.

River Garden's experience utilizing computers in clinical care application began when senior management realized that the government's handwriting was on the wall regarding appropriate use of the Minimum Data Set (MDS). It didn't take a group of nursing home consultants hammering on the point for us to realize that HCFA was extremely serious about establishing a framework for a standardized clinical assessment that could be easily replicated and electronically communicated by all care facilities - i.e., computers were "inevitable."

River Garden Hebrew Home for the Aged is a 180-bed skilled nursing facility located in Jacksonville, Florida. Prior to 1991 our resident assessments were performed on a departmental basis, with both the assessment and plan of care appearing under the departmental sections of the resident chart (i.e., nursing, rehabilitation therapies, activities, social services, dietary). Government surveyors expressed continual displeasure with our multiple locations of care plan information and, as often as not, were critical of the plan as a document which could be reasonably implemented by staff.

It is all too common for clinical staff to complain of being inundated with paperwork. In fact, it's the single most common complaint heard among nursing home staff. In all truth, with the ever increasing paperwork required by government, along with the spiraling demands upon staff for hands-on care, the typical nursing home staff may unceremoniously threaten to revolt when faced with having to learn new computer skills - in short, having "additional work" thrust upon them. The attitude of many has been that if these assessments and care plans need to be completed in accordance with government specifications and regulations - paper compliance - then administrators and directors of nursing (the bosses) should hire additional staff to do them. After all, the work of the nursing home is resident care, is it not?

Perhaps unsurprisingly, then, the resident/client assessment (MDS) and the plan of care are among the most often cited deficiencies by government surveyors. We believe colleagues in the nursing home field may benefit by considering River Garden's experience in implementing a systemized approach to computerizing these functions. It's time for our industry to demystify this process. It is important for management to understand that no automation system will successfully operate without the unequivocal commitment of senior management. The facility administrator and director of nursing must take an active leadership role. If senior management falls short in this, then your efforts are destined to fail. Your staff does not want to travel this road alone.

In order to successfully implement a computerized clinical system, you must affirm in the mind of the computer user that the computer is just a tool designed to enhance work they are already performing. It is not necessary to understand how the machine works! Any successful organization seeking to integrate the computer into clinical programs must recognize that the introduction of data processing will not provide an acceptable substitute for less than adequate professional practice. A computer could easily become the bane of a clinical staff who do not already have in place the elements of good practice.

Management must also recognize that successful introduction of a computer into core areas of its business represents a major change. No facility that has successfully integrated computers into its operations will argue that these machines do not have a major and systemic impact upon its "corporate culture." That is why it is crucial for senior management to understand that they must manage change in an environment that nurtures and supports it, and not hide from it. No matter at what pace it occurs, remember to praise and compliment staff as they progress toward ever higher levels of competence on their computers.

Those are the basic principles, as we see them. Now for the details.

How We Began: The Resident Assessment

As a first, essential step, both the administrator and director of nursing read the instruction manual for the computer software. We know of counterparts in other facilities who haven't gotten around to doing this, and it is amazing, if only considering the investment involved. We then established a 36-bed resident care unit for modeling a computerized assessment and care planning environment. The computer system we chose allowed us to add a Minimum Data Set/Care Plan module to our already existing accounting system. This allowed us to immediately benefit from the general demographic data already available on the system through our accounting office. We added an inexpensive computer terminal and dot matrix printer to the unit conference room, which became our test site.

No staff on the unit had ever had any experience with computers - indeed, only the unit's activities person even knew how to type. Nevertheless, we began implementation on the unit with a very strong core clinical team of registered nurses, social workers, and activities workers - a tenured team which functioned well together and understood the requirements of the manual MDS.

Once we established the basic system at this model nursing station and confirmed that the inevitable "computer bugs" were largely "exterminated", we spent the next 60 days running two systems on the unit - the manual system we had been using and the computer. The computer output was continually tested against the manual work already being performed. At the conclusion of 60 days, we instructed the unit staff to stop performing manual assessments and rely totally upon the computer.

It is important to note here that we used the computer to do the next MDS that was due. We were convinced that it would not serve us well - and would probably create confusion - to enter all the resident assessments we had done to that point into the computer system in one fell swoop.

Once we completed this step we rapidly added additional terminals and printers to our remaining four care units and immediately established a facility "users' group" of clinical staff. We believe a positive assessment outcome is extremely difficult to achieve when the facility uses only a single individual, often referred to as the "resident assessment coordinator" (RAC), to perform this work. This individual, who is (or becomes) far removed from the actual delivery of care, will probably end up developing less realistic care plans. This time and money spent on training multiple members on assessment and care plan development is well spent.

The Users' Group

Our users' group was really a support group for our new computer users. The group initially began meeting once a week during lunch hour, and we started very simply. We wanted staff to very quickly realize small successes with the new equipment. Therefore, we initially taught the core unit staff (RN, social worker, activity worker) how to enter the date and type of the resident's last manual assessment into the computer. Once this was accomplished we showed staff how they could use this information to generate a "pick list" of due dates for the resident's next assessment. No longer would we need to count on fingers and toes the days until the next review.

Once this basic information was in the system, we began to work as a cohesive group with new data entry into the Minimum Data Set. Training on entering and processing the annual, quarterly and "significant change" MDSs proceeded for the next six months, with the group continuing to meet weekly to review problems and share successes. Once our staff became proficient with the keyboard and characteristics of the computerized assessment, its use was no longer viewed as a "time burner."

One aspect of computerized MDSs that staff had an immediate positive reaction to was the automatic calculation of triggers and concurrent production of the RAP summary. No one complained about giving up manual selection of circles and triangles and writing A's and P's on the RAP summary. When the computer did this for them, it was real evidence of the computer's ability to save staff time and work.

The Care Plan

Transferring the data collected from the computerized MDSs to a preliminary draft of a resident care plan required additional effort. While the work associated with the assessment process is relatively black and white, the establishment of a resident care plan allows for professional involvement on the part of the staff. Over time we altered our computerized problem/goal/approach library to truly reflect our facility's standards of care.

Teaching staff how to do this using the computer took a slightly different approach from the MDS training. The Director of Nursing re-taught the fundamentals of how a professional goes about designing a good plan of care. Once we reviewed the processed MDS, we taught staff to say to themselves, "Now tell me about the person who lives on this unit." This is critical to developing a comprehensive plan of care directed specifically toward each resident's needs.

Family Conferences

In our facility, a formal care team conference is held with significant family members approximately two weeks after the resident's admission; the date is generally established on the day of admission by the director of admissions. At this conference the preliminary care plan is discussed with the resident and family so that our team has opportunity to see how its assessment matches up to the family's perception of their loved one.

Depending upon the interests of family, the team will share the completed and processed MDS, including those areas which have triggered and suggested need for care plan intervention. Also, the general goals being shaped for the coming term are shared, and we review all physician orders for medication and treatments.

Subsequent to this initial family conference, family members are continually invited by the resident's social worker to attend a quarterly meeting with the care team. The family letter is sent approximately three weeks prior to the date set for unit care conferences and the family is requested to contact us with a time that is convenient for them, or a change of date if necessary. The staff is extremely accommodating about this - in fact, though it doesn't often happen, evening and weekend meetings occasionally take place.

At the quarterly meeting we go to great effort to share the actual computer-generated, resident-specific and individualized plan of care with family. At subsequent meetings with family we share newly identified problems and changes in established goals and interventions.

We have found this to be extremely well-received by families. The computerized care plan and assessments go a very long way in confirming to the family that this facility knows what it is doing - that it took the time and made the effort to plan for the needs of the resident, that it has both competent and thoughtful staff - in short, that it really cares!

Computer Generated Reports

Every Director of Nursing throughout the United States engages in the clerical activity of number recording, number changing and number verifying. Computers make that task manageable, to the extent that, when the state surveyor walks in and requests "instant" information on resident profiles, we can in fact provide it.

The particular software package in use at River Garden includes several reports available through easily accessible on-screen menus. These include HCFA 672, the Resident Census and Conditions Report, as well as HCFA 682, the Resident Roster. These two reports alone make the "number crunching game" unnecessary. At any time, anyone with access to the system can obtain and print these reports, which include data that is as recent as the last change noted in any resident's condition. Another useful, built-in report is a resident-specific report. This report provides information on such indicators as catheters, feeding tubes, pressure ulcers, tracheotomies, restraints, stasis ulcers, weight loss, oxygen use, psychotropic drug use and other health status factors. As nursing personnel know only too well, these are the areas that surveyors focus upon during a survey. Even more important, these reports are extremely useful as quality indicators, acuity monitors, and identifiers of trends.

As already suggested, the system allows for modification of the care plan library to more clearly reflect the facility's resident population, as well as allow for the addition of localized assessment tools and facility-specific reports. For example, at River Garden we generate nine additional supplemental assessments in nutrition, AIDS, falls, use of safety devices, bladder continence, bowel continence, chemical restraints, skin integrity, and restraint use, all of which are tied to specific responses to the computerized resident assessment. When the item is triggered on the MDS, the supplemental assessment is automatically printed for the resident as well.

The "Blame-Free" Environment

We are all in this together. In the event there is a systemic problem with our work as a result of the computer doing or not doing a particular task, we have made it clear to our staff that an individual staff member will not be held responsible. The Home's administration will take full and complete responsibility for any errors of omission or commission which are the direct result of computer processing error.

Staff realizes, of course, that this "stuff" is important to senior facility management, and will be an area of professional work continuously reviewed for accurate and timely compliance. In line with this, we hold a short clinical meeting each morning and verbally review a computerized listing of resident assessments and care plans due that day. Assessments and care plans that might be overdue become an issue for the entire care team and are quickly updated and processed.

In sum, for any facility to successfully integrate the computer into the process of providing resident care, it will be necessary to challenge the care staff to learn the skills necessary and make them part of their standard professional "toolbox". By working together toward a common goal of staff excellence, the staff will find that the road to computerization need not be difficult. More important, they, the residents and families will come to realize that the potential impact on resident care is significant and welcome.

Martin A. Goetz, MS, MPA, is Administrator and Olga Wells, RN, BSN, is the Associate Administrator and Director of Nursing at River Garden Hebrew Home for the Aged, Jacksonville, FL. The facility utilizes an IBM AS/400 computer with a fully integrated software system from American HealthCare Software Enterprises, Burlington, VT.