Workflow and Documentation Improvement Utilizing Existing Software Technologies: A Journey to Cancer Hospital Accreditation

The Huntsman Cancer Hospital aims to achieve "cancer hospital" accreditation through the American College of Surgeons' Commission on Cancer (CoC). The CoC requires nurses providing direct patient care to have oncology certification or complete 36 oncology-related continuing education unit (CEU) hours during the hospital's three-year accreditation cycle. The current process of tracking and reporting CEU hours involves staff nurses submitting a web form and nurse educators transcribing the data into a Microsoft Excel spreadsheet for report generation. This manual process increases the possibility of transcription errors and is time- consuming. Hospital leadership aims to improve CEU tracking and reporting accuracy and efficiency using existing software technologies. Methods: A workflow analysis was conducted to identify areas for improvement. We worked with business leaders, development team representatives, and decision support representatives to finalize recommended changes and seek needed approvals for development work to be done. Time measurement studies and a questionnaire for user interface satisfaction (QUIS) will be used to evaluate the effectiveness of the interventions implemented. Results: The team anticipates a decrease in overall time spent on CEU hour submissions. However, the improved workflow lacks data visualization, which will be developed once the nurse educator workflow is finalized. Time observational studies showed that the reported time for completion per CEU entry of 5 minutes was longer than the actual process time due to no process for reviewing potential repeat/duplicate CEU entries. The project has the potential to save up to 30.8 hours per 3-year period. Conclusions: The team anticipates a 50% decrease in time spent on poor CEU entry management per nurse educator. However, there were limitations due to a lack of knowledge of existing systems and difficulty contacting those with the necessary expertise. Further development and staffing resources are required to fully optimize the existing technologies and improve workflow processes. A centralized database for CEU tracking would be helpful for both hospitals and individual nurses.