Blue Water Health (ON)

  • Victoria Lucas, Business Director Surgery, Rehab, Oncology and Ambulatory Care Programs, Bluewater Health, Sarnia, Ontario
  • Jennifer McCullough, Director, Performance Management, Bluewater Health, Sarnia, Ontario
  • Renato Pasqualucci, Medical Director, Emergency Department, Bluewater Health, Sarnia, Ontario
  • Mark Taylor, Vice President, Medical Affairs, Chief Quality Patient Safety and Risk Management, Interim Chief of Professional Staff, Bluewater Health, Sarnia, Ontario

Challenges in Standardized Order Set Implementation

This paper describes a patient safety and quality change management initiative of a large community hospital. Prior to the initiative, the organization’s paper patient orders tended to not communicate, integrate or coordinate evidence-based practices through the disciplines, levels of care and services. There was great variation requiring additional oversight with individual physician formats which could be unclear. This lack of coordination and standardization is seen to have the potential to cause medication errors, unnecessary calls for clarification and questions about the orders of the physicians. Implementation of standardized patient order sets will promote and enhance patient safety, and create a more time efficient process while improving quality, modifying practice through evidence-based care, and improving communication, consequently improving patient outcomes.

Partnering with a private agency following the Erie St. Clair Local Health Integration Network request-for-proposals (RFP) process, a multidisciplinary steering committee was put in place. The committee consisted of representatives from physicians, nursing, and Consolidated Health Information Services (CHIS). This committee scoped out the project and set the timeline and planned strategy to address the technical integration of the order sets into Bluewater Health’s system. An operational Order Set Committee was established, led by a respected, enthusiastic physician.

A review of the literature reported that the response of healthcare providers is a major determinant of the success of any change initiative in a hospital. It was anticipated there could be resistance to the change by some physicians. While there was some initial healthcare provider resistance, this was not the biggest challenge the EXTRA team faced. It was computer hardware and software accessibility and support necessary for an organizational-wide change project. Other strategies to implementation have been strong physician leadership and ownership of the project, new order sets integrated into workflow, frequent multifaceted communication and targeted education opportunities, and high rate of physician involvement with physician champions driving the adoption for their respective groups. Monitoring, auditing and feedback have been successful strategies as order set usage is reported at standing physician committees and program committees. Qualitative inquiry using physician focus groups was completed to gain insights about introduction of practice change for physicians.

Prior to IP implementation there were 281 physician-specific legacy printed order sets which were not founded on best evidence-care. They have been replaced with 165 formal evidence-based standardized order sets. After six months of online availability, utilization is very close to the target of 80% by September 2013 (76% for inpatients, 81% for day surgery). Improvement is seen in venous thromboembolism prophylaxis for Medical and Surgical patients from as low as 12% prior to order set implementation up to 24%. Despite an increased number of orders being processed by pharmacy and nursing, these groups report less time spent clarifying and questioning illegible handwritten orders (3.7 minutes to 2.0 minutes per prescription order on weekdays; 6.8 minutes to 3.6 minutes per prescription order on weekends).

Standardization enables evidence-based practice. Previous experiences can be built upon by other organizations. Focus groups are useful strategies to involve broad stakeholder participation in decisions about readiness and processes. The importance of a strong IT infrastructure must not be underestimated with any future technology improvements. With new strategic planning direction at Bluewater Health, a strong emphasis has been given to evidence-informed decision making and the need to address challenges and barriers to implementing this organizational transformation.