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TownHall: Nursing Flow Sheets and the Art vs Science of Nursing with Anika Gardenhire

Bill Russell: [00:00:00] Today on Town Hall

Anike Gardenhire: (INTRO) Don't let historical inertia block your thinking. I think that there are really smart people who have really great ideas, write it down, seek it out. See if you can make whatever the change is that needs to be made so that it comes true

Reid Stephan: for the future.

Bill Russell: My name is Bill Russell. I'm a former CIO for a 16 hospital system and creator of This Week Health.

Where we are dedicated to transforming healthcare, one connection at a time. Our town hall show is designed to bring insights from practitioners and leaders. on the front lines of healthcare. .

Alright, let's jump right into today's episode.

Reid Stephan: Welcome to this week, health Town Hall conversation.

I'm Reid Stefan, CIO of St. Luke's health system based in Boise, Idaho. And I'm joined today by my friend Anika Gardenhire, who is an rn, and currently the Chief Digital and Transformation Officer of Arden Health in Nashville, Tennessee. Anika, how are you on this beautiful Wednesday morning?

Anike Gardenhire: Doing well.

Nice to [00:01:00] hang out. Thank you for having me.

Reid Stephan: Yeah. Excited about this conversation, so I'm gonna tee it up. I'm a monologue just for a minute, and then most of this will be you talking because you just have great thoughts in this space. So we've had like a lot of organizations, we've had some great success with our ambient listening journey to date.

But it's largely benefited providers apps, not our nurses. And so as we hear these anecdotal stories of how amazing this has been for our clinicians, in the back of my mind, I have this nagging weight of like, what about our nurses who face, I think, and even greater clinical documentation burden. So that's been in my mind for the last few months.

And then you and I are at an event earlier this spring. And you were on the stage sharing some thoughts about flow sheets, and I would summarize it as flow sheets are the worst thing to happen to medicines at sepsis. And maybe that's too extreme, but just you had some really insightful comments that I'd never thought about before.

So I just wanted [00:02:00] to have you on the show and just chat about that. So let's just start there, like, what's wrong with nursing flow sheets today? If we can assume that the intent behind them was good. The idea was to create structure, to be compliant, to be able to track trending, but the reality maybe doesn't quite fit the altruistic intention of flow sheets.

There's too many fields. It's hard to find what matters. Sometimes it feels like there's an emphasis on documentation over patient care. We have these data graveyards, so you have this great background as a nurse as well. Just walk us through like the history of flow sheets and why there's such a bane of your existence and our existence today.

Anike Gardenhire: First I will start with, I do think all of the good intent was there, right? And I, I think part of the good or the bad, in fairness to everyone who has to deal with me on this topic and on others I have the benefit of, having been a clinician.

I, I started my career at the bedside and spent several years there. I was a [00:03:00] travel nurse. I learned documentation on computers. If you could even call them that at the time, right on dos based systems of, F nine to save an F 12 to delete, deal. I remember I jokingly say that I became a nurse informaticist when an informaticist met.

You knew how to use the mouse. And so, I think there was a lot of really good intent and I spent a lot of years documenting on paper when the paper was the trifold, right, and you were creating the trend lines by coloring in a little dot and then literally drawing the line so that others could use it.

I am a nursing nurse, right? I think every single member of the clinical care team is really important, and I think it works best when all of the specialties come together in concert, in support of the patient. And I genuinely believe in nursing as the coordinator of care. And I think that it's really important when, respiratory and PT and OT and speech if needed and

lab services and pharmacy and the provider, right? And everybody is [00:04:00] coming together in alignment to their disciplines. And when I think about, especially acute care nursing as the coordinator of care, but I also think about it in home care and in other settings where nursing plays that role. I think about the importance of people being able to digest, right.

What is being documented by the person who is meant to coordinate all of the care. The person who's meant to help support every other type of specialty. The person who's really meant to help support and provide clarity of message across the specialties. And oftentimes, especially in acute care, quite frankly, the person who's seeing the trend of a patient for the longest amount of time, just simply because you're spending 12, sometimes, maybe 14, sometimes maybe 16 hours with that individual.

And so you are seeing them actively improve or decline over a period of time in ways that it's just not inherent to the workflow of the way other disciplines might be interacting with the patient. And so for [00:05:00] me, when I think about sort of the origination of nursing and right, and I go back to like my old sort of nerdy Nightingale days, and I think about the importance of like how we discovered the importance of hand washing and like what was happening in the fields of literally caring for, patients post World War ii and sort of why this discipline is so important.

I go, how in the world did we get from there to like writing all down in Excel? And I think that's where I sort of have the disjointedness or where it comes apart in my head and I go, there was a time when the narrative note for nursing was really important. It was important for handoff. There was clarity of documentation in the narrative.

It was this really beautiful summary that I think clinicians created in order to provide sort of that overall bite size. If you really wanna know this person in this bag. And about what happened over the last duration of my, you know, set of hours with them. Here is a snapshot that can [00:06:00] help you understand that.

And I think that the intent of sort of the transition to flow sheets was all good intent, right? Quality measures and trends and core measures, right? Folks will remember those from the providers and, and really supporting them in that and, really trying to make sure we had a better understanding of how to capture that amount of time that a clinician.

Especially if a nurse was spending with a patient. I think that was all good. And I think that when we think about nursing as both an art and a science, I think we spent a lot of time focused on trying to figure out how to capture the science in the discrete fields and in the trends that we might've forgotten.

How to make sure that we provided a documentation capture that would also allow for the art. And I think the art is really important and I would hate to see us lose that from a documentation perspective and as a profession. I think it's really important.

Reid Stephan: So based on your experience as a clinician to the bedside, just to put it in real terms, give an example [00:07:00] of the science of nursing and the art of nursing, just to help listeners maybe visualize that better.

Anike Gardenhire: nursing, sometimes we describe it as like an aura or that feeling or that thing that a really experienced nurse can say about a patient and that happens in their gut and they're absolutely right. And it only comes from having been at the bedside for many years or having gotten to know the patient and the family.

And so when I think about it, I think about from a science perspective and, I say this all the time. I remember when like the monitors at the bedside, went from like, 12 to like 18, I think like up to like 24 elements. Like you could get like deep CO2, and it was a really interesting sort of way to see the screen.

And the little boxes get smaller and you have more and more trend lines. And I think that goal was the science right? And you have nurses, especially in ICUs who are trying to titrate drips every five minutes and all of these calculations are happening and that's really [00:08:00] important. And I think, nurses and clinicians are really good at that.

And then there's the conversation that you had with a patient while you were holding their hand. While you are looking at the monitor and thinking to yourself, what would actually give this patient the encouragement that they need in order to fight the battle? So there's the, what we're doing on the outside with the science, and then there's the inherent innateness that's so important to the individual who is lying there, who is having this experience that helps you understand whether or not, for example, somebody is in this fight with you or really exhausted.

Or trying to still figure out whether or not they want to be in the fight. And I think that those things are really important for us to capture and understand. Yeah. For us to be able to share with family and other colleagues that might be walking in the room for every person who's having an interaction to be like, oh, it would be [00:09:00] great if every person who came in the room

reminded this person about the family or this statement that their daughter made. Or the fact that somebody brought, a beloved pet to see them, two days ago, and they're super excited for them to come home and like, those are the types of things that keep the individual. In the fight with us as we're working to help people reach their goals because these are not our goals.

These are the person who's laying in that bed, the person who's receiving the care, the person who's in the treatment. These are their goals that we're trying to help be realized.

Reid Stephan: love that. As you were describing that, I'm thinking, so how do we then create that capacity for our incredible nurses so they can have more time to focus on the art of it.

That healer to human connection that really, I think in a lot of cases is the demarcation between a patient saying, I have a good nurse, or I have a bad nurse. It's that part of it. Okay, so I'm aligned with you. Like, we know why we have flow sheets today. We can [00:10:00] understand that there's regulatory creep, maybe an EHR limitation.

Maybe misaligned assumptions that we make along the way. So we've got this today, this tug of war balance between clinical needs compliance, billing. So from your leadership seat today, how should systems balance these pressures? Like what can they do to try and figure out a way forward?

Anike Gardenhire: So I think it's really important to just continue to question which of these things are actually requirements and like how much of it is.

Sort of grounded in historical inertia, I sit in rooms sometimes and people will say, well, you can't mess with the flow sheet. It's a regulatory requirement. And I'm like, oh my gosh. Real, like, really? Right. And I'm always so surprised to hear someone say that because I'm going, tell me where.

Yes. Tell me, Tell me the place where, some board of nursing in some state, or some regulatory body, or the Joint Commission or someone said, we definitely do not consider this good documentation if it's not a [00:11:00] set of boxes and dropdowns. And I'm going, I don't think anybody's actually said that or written that down.

And so I think to your point, coming back to the table to say what is it we're actually trying to do? Okay. I wanna make sure we can capture the trend over time when it comes to a patient. I do wanna make sure discrete data elements and trend lines are there. Is that nursing documentation or is that something that we need to get out of the surround?

I really wanna understand nursing's responsibility for the environment of care, right? And how that environment is being provided. That is conducive. That's everything from the promotion of healing to the way that we think about skin management to the way that we think about communication, to the way that we think about coordination with other specialties.

How do I get that documented in a way that's meaningful? And yes, nurses are very important to revenue capture. I wanna make sure that we're capturing charges. I wanna make sure I understand how non-chargeable, disposable items are being utilized and transferred and all of those types of things. And so I think there is a mix of how we get that [00:12:00] understanding That is everything from something clinicians need to document.

To something we need to be pulling in from a device in an automated fashion to something we need to be thinking about, whether it comes from a pictorial collection to something that happens between that nurse and an articulation out loud to another clinician in the room or to the patient directly.

And so I just think it's an opportunity for us to go back and say, okay. This was the actual intent. If I were to take what we're doing today and ask myself, are we capturing the actual intent? I'm not always sure that we actually are, and I think that's the place I'm trying to get us to go back to is to just take another look at the question.

I think about things like continuous bladder irrigation, right? When you're trying to document those and you go to a discreet field and your choices are like clear pink and red. Well, well, CBI is literally like a capture over time. It's more about is [00:13:00] it pinker or reder than it was. Or less red, less pink, closer to clear.

And the dropdown is not exactly giving me the ability to actually state what is happening with the patient. And I actually think when it comes to the nursing assessment especially, that happens more so than we think.

Reid Stephan: let's build on that then. And let's imagine this better future where we have a solution that's, it's intuitive, it's context aware, it's minimalistic, it's high value activities, it truly is patient centered.

If you could wave your magic wand, and I've heard you have one in your desk and redesign nursing documentation, what would it look like?

Anike Gardenhire: It's such a good question. First and foremost, I would say that design would happen with a large number of nurses who are practicing at the bedside today. First and foremost, I wanna say that out loud again for anybody who might be listening to me.

Reid Stephan: Design because too often we design it and then we go to the nurses and say, Hey, look what [00:14:00] we've done. Isn't this great?

Anike Gardenhire: I just wanna say it out loud, right, because I it, it, you know, that design would happen with clinicians. Noted who are actively practicing at the bedside today. And while I am a nursing nurse and absolutely love it, that is not my situation today.

And we have a really awesome chief nursing officer and a really awesome nursing leadership team and great clinicians at the bedside. When I think about it from the lived experience that I've had, I would say there would be a couple of things. One. I would not be expected to write down anything that comes off of a device, right?

Literally, if there is a number that comes off of something in my vicinity, I would not be expected to write it down. What I would be expected to do is to look at the number and then document the things that are happening and what I'm doing about the fact that the numbers [00:15:00] say what they say. I tell people all the time when those monitor changes and the number of discreet fields changed over time.

It always drove me crazy because I would be like, what exactly am I supposed to do with this one now? Right. And I would say all the time, I don't need another data element, I need a suggestion. I need a sentence. Like put something out there. Yeah. Because this is true. Right, and so I think it would be that, right?

Those things would be being analyzed in the background and there would be suggestions, and I would take in that suggestion plus the contextually aware information that I am getting from my five senses. Right. My sight, my touch, my feel, my hopefully not taste like, you know, but my smell, right, Uhhuh. And so that additional information I would be working to analyze.

And then what I would actually be sharing is my knowledge and thought process that is leading me to an intervention. Right. Yeah. I would [00:16:00] provide my logic outside in to say, Hey, I'm seeing this this is a suggestion, but I am feeling the skin and it feels like this, and I am looking at the person, and the palor is this, and the logic is not adding up, and so I am going to do this because those things are true.

Right. Yeah. And so for me it would be that type of contextually aware information and then as a coordinator, I would be articulating also who else might need to look explicitly at what It would be great if the provider, as the patient's advocate. Do this. I really would love to see if respiratory would come and see my patient because of Y, and at least from my perspective, I would be supportive if the provider also ordered these things because of X.

Right? I'm not overstepping my license as the patient advocate. I have thoughts, suggestions, and based on my education and experience, these things would also be great from a [00:17:00] patient outcome perspective. Right? And so for me, I think that it would be. Much more of an articulation, much more of a capture of thought process and logic.

Much more of a contextually aware, asking me questions and looking for items that I get as the person responsible for the environment of care, promotion of healing, right? Those types of things. And transparently, I think that we take another look at nursing diagnoses, which I think we sort of let fall away from the wayside, especially when it comes to acute care.

And be talking about those a lot more. Than we might be today.

Reid Stephan: So with that, and I love everything you just said. What role do EHRs play then in helping create this better future space?

Anike Gardenhire: Yeah, I mean, I think it's a really important role. There are a couple of things. One, I think EHR companies would be a great convener.

Of the nurses who are practicing today who need to come together and design this future. And so I think that's the first place is how do you start to bring the right [00:18:00] people together along with the appropriate nursing organizations and transparently other stakeholders who I think will and should be highly interested in what the future of nursing.

Overall clinical but especially nursing documentation looks like. And so I think having that, that convening role would be really helpful. Starting to help clinicians and nursing think about the fact that going to a computer and that sort of human computer interaction experience.

Could also be thought about differently because I think for nursing especially, there is the quote unquote, the way that we think about the documentation flow. And then there's a really important workflow, like the true workflow of when I physically stand at the computer and the keyboard, and how I turn my body to the patient versus the computer.

And how I think about what that looks like during specific times like. Passing meds, right when I'm working to scan the med and scan the patient and I'm still thinking about my five [00:19:00] rights, but looking at what's happening with the barcode scanner, if I'm getting any alerts and those types of things.

And so I think it's also an opportunity to think about how do we create a more holistic and supportive experience for even the way we just stand at the room and position the devices and those types of things. then I think that EHR companies would be really great at helping to convene what is actually required.

In real life. From a documentation perspective. And so how do we get the chief quality officers and the revenue integrity teams and the right to come together and talk about from a minimalistic perspective, what do we really need to get out of this from a, a clinician perspective, especially from a nursing perspective, but broader clinically as well, in order to do the things that we need to do, we wanna be able to have appropriate reporting.

We wanna make sure that we have appropriate capture in order to do that. We wanna be able to support all of the places that [00:20:00] need that information from abstracting to reporting to CMS. And we wanna make sure that from a revenue integrity perspective, that we're supporting, right? That highest acuity documentation so that we're telling the holistic patient story through our ability to code clinically.

And so. I do think those things are really important, but I think that there's an opportunity around having clinicians come together to think about the future and having EHR providers come together to say, one, you can think about the future. There are things that we can do now that we literally could not do in the past, and it creates a certain type of permissive rethinking.

And then I think that it's important to make the type of investment that we need in order to be supportive about what the future of clinical care really is.

Reid Stephan: I love that idea of the EHR as the aggregator or the source of truth to help us distill between what really is required versus the inertia.

I can't remember the phrase you used, but I loved it. [00:21:00] Like we just accumulate these historical decisions and we treat them as like carved in stone truths and that aren't, and so that would be a great way for EHR is to help us dispel those myths and give back some productivity.

Anike Gardenhire: Absolutely.

Reid Stephan: we haven't said the word ai, but we will, and you've not said it, but touched on it, but certainly like in all of this.

We're living in an era now where we've got some really compelling tools that are here now and will be coming in the future that can help to address some of this. Are there any models or pilots that you're doing at Ardent or that you've seen elsewhere that are gonna help to maybe address some of these challenges we're talking about?

Anike Gardenhire: Absolutely. I mean, like most organizations, right? We are rolling out pilots and actually preparing to scale ambient listening technology and we talked about this at the beginning where a lot of that is focused in the provider space. My hope is to see that rapidly expand to other clinical types and transparently other settings, right?

We [00:22:00] talk about this a lot. As it relates to oftentimes, for example clinic settings. The goal I think is to press these types of solutions forward into acute care. I think there'll be great solutions for home care. I hope is to continue to see this type of technology expand to multiple settings of clinical care in addition to multiple disciplines of clinicians.

The other piece is really I think that the, virtual nursing and virtual attending types of solutions are really important as we think about retention, as we think about keeping the knowledge base right inside of the healthcare profession and making sure that we can be supportive.

As, new generations of clinicians are coming to the bedside. I think about again, the ability to capture that discreet information and being able to do that in a minimally invasive continuous monitoring and getting the most insights possible. So how we do, what is the future of vital signs [00:23:00] capture?

What is the future of the number and types of vital signs we need to capture and how should that be helping us to sort of, predict in a more precise fashion about what might be happening with a patient and even getting ahead of a patient when they might be making a turn. And those are the types of things that, from a clinical care perspective, I think are really important.

Now I do think, there is going to be a time when we have more supportive. Diagnoses for clinicians transparently, I think appropriately. So we are a bit of a ways out from that, but when I think about everything from falls to sitter management to virtual care to, being able to do analysis on discrete data elements to have better support for suggestions better support for what an outcome might look like and prediction.

I think those things are really there now and are ripe for implementation and scaling. [00:24:00] Transparently. I wouldn't be doing my due diligence as any type of CDO DTO or IO if I didn't put a plug in for the fact that we have to make these things appropriately cost effective. Yes. Right.

We're all managing budgets. And so when people ask me what I hope to get out of ai interestingly, it's all of the things I just mentioned, and then I also put a plugin for hopefully a commodity level pricing on compute so that we can actually democratize these tools.

Reid Stephan: Well said. And we've got this, perfect storm of aging population, aging workforce, slow birth rate, like we're gonna have to bring these tools forward, but also to your point, in a way that are really cost effective.

Awesome. So as we wrap up, Anika, just final thoughts, like any closing words of encouragement you have for colleagues like you and I, nurse informaticist, frontline staff, like those that are trying to drive change in this area. What advice or encouragement would you offer them?

Anike Gardenhire: I would offer just two [00:25:00] things.

Be curious and think really big, right? Don't let historical inertia block your thinking. I think that there are really smart people who have really great ideas, and I think they pop up oftentimes while you're in the midst of doing and from friction, write it down, seek it out. See if you can make whatever the change is that needs to be made so that it comes true

Reid Stephan: for the future.

Anika, thanks so much. Great to visit with you and appreciate the insights you've shared.

Anike Gardenhire: Thank you.

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