Lindgren Carolyn L, Elie Leslie G, Vidal Elizabeth C, Vasserman Alex
Center for Research and Grants, Baptist Health South Florida, Coral Gables, FL 33143, USA.
Comput Inform Nurs. 2010 Mar-Apr;28(2):74-8. doi: 10.1097/NCN.0b013e3181cd7f2d.
In reaching the goal for standardized, quality care, a not-for-profit healthcare system consisting of seven institutional entities is transforming nursing practice guidelines, patient care workflow, and patient documents into electronic, online, real-time modalities for use across departments and all healthcare delivery entities of the system. Organizational structure and a strategic plan were developed for the 2-year Clinical Transformation Project. The Siemens Patient Care Document System was adopted and adapted to the hospitals' documentation and information needs. Two fast-track sessions of more than 100 nurses and representatives from other health disciplines were held to standardize assessments, histories, care protocols, and interdisciplinary plans of care for the top 10 diagnostic regulatory groups. Education needs of the users were addressed. After the first year, a productive, functional system is evidenced. For example, the bar-coded Medication Administration Check System is in full use on the clinical units of one of the hospitals, and the other institutional entities are at substantial stages of implementation of Patient Care Documentation System. The project requires significant allocation of personnel and financial resources for a highly functional informatics system that will transform clinical care. The project exemplifies four of the Magnet ideals and serves as a model for others who may be deciding about launching a similar endeavor.
为实现标准化优质护理的目标,一个由七个机构实体组成的非营利性医疗系统正在将护理实践指南、患者护理工作流程和患者文件转化为电子、在线、实时模式,以供系统内各部门和所有医疗服务实体使用。为为期两年的临床转型项目制定了组织结构和战略计划。采用了西门子患者护理文档系统,并使其适应医院的文档和信息需求。举办了两场有100多名护士和其他健康学科代表参加的快速培训课程,以规范前10个诊断监管组的评估、病史、护理方案和跨学科护理计划。满足了用户的教育需求。第一年过后,一个高效、实用的系统初见成效。例如,一家医院的临床科室已全面使用条形码药物管理核对系统,其他机构实体也处于患者护理文档系统的实施阶段。该项目需要为一个将改变临床护理的高功能信息系统大量投入人员和财务资源。该项目体现了四项磁石医院理念,可为其他可能决定开展类似项目的机构提供借鉴。