Alleviating the burden of documentation to focus on what matters (Institute of Healthcare Improvement, 3 November 2022)

Summary

Most healthcare systems across the globe are dealing with the reality of limited resources and staffing shortages. Therefore, it is more important than ever to ensure that health care professionals spend time on doing what matters most and providing the most value for service users.

Meaningful time spent face to face is a high priority for both service users and health care professionals. Paying more attention to computers than people because of the demands of burdensome documentation diverts our attention from direct care. It is a situation that is unsatisfactory for all parties.

The Danish municipality of Sønderborg, a safety leader in nursing home and home-based care for more than a decade, decided to see what could be done. With improvement science already embedded in their organisation, they decided to take a deep dive into their processes as a first step. Mistakes in documentation, coordination, and communication have been identified as among the top 10 of root causes of patient safety incidents in Denmark, so it made sense to start there.

Patient safety is often cited as the reason for documentation, but some research indicates that burdensome documentation is associated with increased medical errors, mistakes in documentation, and burnout among health care providers. Working from the theory that safely simplifying or streamlining documentation would free up time for direct care, Sønderborg and the Danish Society for Patient Safety embarked on an improvement journey that started with understanding the workflow of documentation that enabled staff to seek and share information from one another to plan and perform different tasks.