Working from the Ground Up: Why Documentation is the Key to Practice Success

Jacob Lynch Electronic Health Records (EHR)

Smiling doctors and nurses discussing over laptop in hospital

The healthcare system is constantly changing. As leaders, it can sometimes feel overwhelming trying to keep up to date on the latest requirements, not to mention training staff and providers on the changes. Last year, by the time I had a firm handle on how my practice would capture and report the MIPS data, the third quarter was almost over. Rules, laws, evidence-based practices, performance metrics – it is all changing so fast. So, how do we keep up?

It is easy to maintain a sense of perspective when we attend meetings or listen to webinars. The speakers all seem to have everything under control. But when we return to the office, it can be difficult to envision how to ensure compliance and justify changes to staff and providers. Believe it or not, getting to a place where compliance is easy, change is effectively managed, and staff are happy isn’t as daunting as it might seem.

By using documentation, practices can keep pace with change, remain agile, and be ready to move when the situation calls for it. It is unreasonable to expect staff to adapt to changes that are communicated verbally or via email. There is simply too much to keep track of. Documentation creates structure for staff and providers, and it helps them become self-directed by supplying the resources they need on the job. Most importantly, documentation creates a strong foundation to build upon as more changes come in the future.

In this four-part series, we will examine strategies to create accurate and useful documentation, keep that documentation current, ensure staff and providers are compliant, and respond to whatever changes are on the horizon.

Working from the Ground Up: Why Documentation is the Key to Practice Success

The best way to create a well-run and compliant clinic is documentation of the practice workflows. Documentation can come in many forms, whether it is a tip sheet, an operations manual, a job aid, or one of many other common terms. No matter what you call it, the key to great documentation is to make it useful for the staff and providers.

So, what makes great workflow documentation? Here are six tips to ensure that your documentation creates a solid foundation for your practice.

1. Consistency

Documentation should always follow the same format. It should include the date the documentation was created and the date of the most recent update. It should also include the name or title of the person who is responsible for maintaining the documentation and the staff to whom the documentation applies.

It is also important to maintain a consistent design and format. Documentation should have the same colors, headings, bullets and/or numbering, and fonts, as well as any logos or practice branding. If the documentation is available on the practice intranet, it should be provided in a PDF format, so it cannot be edited by staff – either intentionally or unintentionally.

2. Location

Documentation should be easy for staff to access. Traditionally, many healthcare settings have used binders to store policies and procedures. If your practice is printing and binding documentation, be sure it is accessible to every employee. One copy for every 3-4 employees typically works best.

Intranet sites are another option for storing documentation. More than just a repository for practice policies, an intranet site can be a one-stop shop for staff. It can provide a place for human resources policies, daily updates, announcements, participating provider lists, and much more. The intranet is an ideal location to store workflow documentation. By using an intranet site as a central location, the practice can cut down on staff using old or outdated workflows.

3. Organization

A well-organized documentation repository is key for adoption by staff. The staff needs to be able to find the right document within a few seconds, before being pulled in another direction. Ideally, documentation should be organized by role or grouped by similar tasks.

As you build your documentation, it is also important to think about how much information to put in one document. As a general rule, smaller documents are easier to manage. Staff can find things without scrolling through multiple pages and leaders can easily update workflows as changes occur. If your organization uses a change control or approval process, a supervisor may be able to approve minor changes to a workflow instead of bringing a gigantic document before a committee just to make one small change.

4. Clear Purpose

Whenever possible, documentation should briefly explain the rationale behind the policy or workflow. Justifying why a staff member is required to do a task a certain way fosters healthy communication between staff and leadership. That way, when changes are made the staff will be able to clearly see how the new workflow is related to a new requirement or policy.

Having a brief purpose statement also helps leaders to understand the basis for a workflow and evaluate when changes are needed. I once heard a horror story where a practice had been having patients sign forms, which were then collected and bound, then filed away in the basement. The practice had been renting extra space to store these forms, and as it turns out the forms were used for a 1971 study. Over 40 years of unnecessary work and storage fees, simply because no one ever looked at why the workflow was in place.

5. Simplicity

Documentation should cover what it needs to, and not much else. Workflows for a task should cover the basic steps in that task and the most common exceptions, if applicable. If the documentation to order an interpreter for an appointment is eight pages long, it is less likely that staff will follow through with the workflow. A good rule of thumb is one or two pages for most tasks, with more complex tasks being three or four pages.

6. Visual Appeal

Documentation is more likely to be used if it is visually appealing. Most documentation will be created using Microsoft Word, even if it is later converted into a PDF. Be sure to use bullets, headers, different fonts and other ways to emphasize your text. If you are printing your workflows, use color to make the document vibrant.

Pictures are also a great way to show a process in simple steps. The Windows Snipping Tool allows you to grab screen shots and paste them into a document. Be sure to size the screen shots so they do not take up too much space but are still readable. For more complex processes, use flowcharts or diagrams. Microsoft Visio and are great resources to create high-quality and professional diagrams.

I hope that these tips help to build a strong foundation for your practice. Next time, I will offer some suggestions on where to start with your documentation project and how to engage the right people in your practice to help get it all done!