CAH staff perceptions of a clinical information system implementation.

OBJECTIVES: This study examines staff perceptions of patient care quality and the processes before and after implementation of a comprehensive clinical information system (CIS) in critical access hospitals (CAHs). STUDY DESIGN: A prospective, nonexperimental design, evaluation study. METHODS: A modified version of the Information Systems Expectations and Experiences (I-SEE) survey instrument was administered to staff in 7 CAHs annually over 3 years to capture baseline, readiness, and postimplementation perceptions. RESULTS: Descriptive analyses examined 840 survey responses across 3 survey administrations and job categories (registered nurses [RNs], providers, and other clinical staff). Analysis of variance compared responses for main effects (ie, administration, staff position, hospital, and cohort) and interactions between groups over time. Correlations examined the relationships between variables. In general, the responses indicate a high level of positive perceptions regarding the processes and quality of care in these hospitals. For most of the items, responses were quite consistent across the 3 survey administrations. Significant changes occurred for 5 items; 4 reflecting information flow and increased communication, and 1 reflecting a decrease in improved patient care. Overall, providers had lower mean responses compared with nurses and other clinical staff. Significant interactions between administrations and job categories were found for 4 items. CONCLUSIONS: Even though staff had overwhelmingly positive perceptions of patient care quality and processes, significant differences between providers, RNs, and other clinical staff were observed. Variability was also found across CAHs. Research on CIS implementation in small hospitals is rare and needed to guide the identification of factors and strategies related to success.

Decisional involvement: staff nurse and nurse manager perceptions.

Enhancing involvement in organizational decisions is one strategy to improve the work environment of registered nurses and to increase their recruitment and retention. Little is known about the type of decision making and the level of involvement nurses desire. This was a descriptive study exploring staff nurse and nurse manager ratings of actual and preferred decisional involvement and differences between staff nurses and nurse managers. A sample of 320 RNs from a Midwestern health care network was surveyed using the Decisional Involvement Scale. Nurse managers and staff nurses had statistically significant differences in their perceptions of who was involved in actual decision making in the areas of unit governance and leadership and collaboration or liaison activities. There were statistically significant differences in preferred decisional involvement between staff nurses and nurse managers in the overall DIS scale and the subscales of unit governance and leadership and quality of support staff practice.

Implementation of a telepharmacy service to provide round-the-clock medication order review by pharmacists.

Purpose The implementation of a telepharmacy service to provide round-the-clock medication order review by pharmacists is described. Summary Seven critical access hospitals (CAHs) worked collaboratively as part of a network of hospitals implementing the same electronic health record (EHR), computerized prescriber-order-entry (CPOE) system, and pharmacy information system to serve as the health information technology (HIT) backbone supporting round-the-clock medication order review by pharmacists. Collaboration permitted standardization of workflow policies and procedures. Through the HIT backbone, both onsite and remote pharmacists were given access to the medication orders, the pharmacy information system, and other patient-specific clinical data in patients' EHRs. Orders are typically reviewed within 60 minutes of when they are entered into the system. The reviewing pharmacists have remote access to the EHRs in each CAH. After completing the clinical review, the pharmacist selects the appropriate medication to dispense from the CAH's formulary. If the medication order is not made using the CPOE system, the order is scanned into a document and sent via e-mail to remote pharmacists. The pharmacist enters the necessary information into the EHR and pharmacy information system. The medication order review process from this point forward is identical to that used for medications ordered via CPOE. The new medication order is then entered into the EHR, and the CAH nurse can proceed with the order. Conclusion The implementation of a telepharmacy model in a multihospital health system increased access to pharmacy services, allowing for round-the-clock medication order review by pharmacists.

A network collaboration implementing technology to improve medication dispensing and administration in critical access hospitals.

We report how seven independent critical access hospitals collaborated with a rural referral hospital to standardize workflow policies and procedures while jointly implementing the same health information technologies (HITs) to enhance medication care processes. The study hospitals implemented the same electronic health record, computerized provider order entry, pharmacy information systems, automated dispensing cabinets (ADC), and barcode medication administration systems. We conducted interviews and examined project documents to explore factors underlying the successful implementation of ADC and barcode medication administration across the network hospitals. These included a shared culture of collaboration; strategic sequencing of HIT component implementation; interface among HIT components; strategic placement of ADCs; disciplined use and sharing of workflow analyses linked with HIT applications; planning for workflow efficiencies; acquisition of adequate supply of HIT-related devices; and establishing metrics to monitor HIT use and outcomes.

Creating a shared formulary in 7 critical access hospitals.

PURPOSE: This paper reports a case study of 7 Critical Access Hospitals' (CAH) and 1 rural referral hospital's successful collaboration to develop a shared formulary. METHODS: Study methods included document reviews, interviews with key informants, and use of descriptive statistics. FINDINGS: Through a systematic review and decision process, CAH formularies ranging in size from 667 to 1,351 items were compared, rationalized, and consolidated resulting in an 803-item shared formulary. While the individual CAHs were generally expected to list and stock the same 803 items in the shared formulary's pharmacy information system, they could individually determine the amount to be stocked for each item, as well as stock additional items not included on the shared formulary to reflect local provider preferences and services provided. Final stocked formulary items ranged from 592 to 786 items among the 7 CAHs. Major challenges and lessons learned in the course of developing a shared formulary related to: Meeting Logistics, Facilitator to Manage the Process, Organizing the Review Process, Management Support, Stakeholder Participation, Working Collaboratively, Decision-Making Process, Clarity of Charge, Meeting the Needs of Unique Services, Communicating with Providers, and Adjusting to a Shared Formulary. CONCLUSIONS: Collaborating in the development of a shared formulary allows for a greater range of decision-making expertise, shared workload, and an improved formulary. An organized and well-managed group decision-making process is essential to a successful collaboration.

The relationship between RN job satisfaction and accountability.

The purpose of this descriptive correlational secondary data analysis is to describe the relationship between job satisfaction and accountability among registered nurses with clinical responsibilities employed by a rural health care network in the Midwest. The response rate from the primary study is 39%, with 337 RN respondents. The sample for this secondary analysis is 299. The instruments used to measure accountability and job satisfaction are the Specht and Ramler Accountability Index-Individual Referent and the McCloskey-Mueller Satisfaction Scale (MMSS). The results indicate that accountability is perceived to be relatively high and job satisfaction is moderate. Accountability and job satisfaction are significantly correlated at a moderate level. The correlations between the subscales of the MMSS and accountability are all statistically significant but low. The subscales with the highest correlations (e.g., control and responsibility, praise and recognition, professional opportunities, scheduling) provide direction for nurse administrators about important target areas for improvement.

Perceptions and characteristics of registered nurses' involvement in decision making.

PURPOSE: This study aimed to determine the level of actual and preferred decisional involvement and ascertain whether there is decisional dissonance among registered nurses (RNs). SUBJECTS AND METHODS: A convenience sample of 196 RNs completed a demographic form and the Decisional Involvement Scale, a tool that measures actual and preferred decisional involvement for RNs in 6 categories: unit staffing, quality of professional practice, professional recruitment, unit governance and leadership, quality of support staff practice, and collaboration/liaison activities. From these data, the level of and difference between RN's actual and preferred decisional involvement was analyzed. In addition, the impact of level of education, years of experience, hours worked per pay period, and work setting on actual and preferred decisional involvement were measured. RESULTS AND CONCLUSIONS: A statistically significant difference was found between RNs' actual and preferred decisional involvement, with RNs preferring more decisional involvement than they actually experienced. Work setting was the only variable to which a difference could be attributed. Further study is warranted to find causes of decisional dissonance and interventions that could help alleviate the problem and potentially increase job satisfaction.