CLC Documentation Improvement Workgroup at Syracuse VA Medical Center
May 2025
CLC Documentation Improvement Workgroup
at Syracuse VA Medical Center
CLC
Syracuse VA Medical Center
Syracuse
,
NY
United States
Kathleen Kearney, RN and Angela Wheeler, RN Amanda Cannon, RN Lisa Woolridge, RN MDS, Tiffany Reeser, RN RAC Rose Marie Nemerow, RN Sarah Cross, RN Grace Darko, RN Justin Boswell, RN Shakeela Booker, RN Nicole Janvier, LPN Lynn Patchen, LPN, Matthew Dupee, LPN, Christina Norton, LPN Julie Cox, LPN Elizabeth Sterling, LPN Stacey Adamy, LPN Alexa Rivera, LPN Courtney Lefave, LPN Thomas Hebert, LPN, Adekemi Abolade, NA Gabrielle Bastable, NA
The Community Living Center operates as a 28-bed unit dedicated to providing care for veterans requiring short-stay, sub-acute rehabilitation, and long-term care. In July 2024, following a conversation with a staff member regarding veteran care documentation, I conducted a preliminary review of five veteran charts and identified significant deficiencies in nursing documentation. Subsequently, I collaborated with our Community Living Center Educator, Angela, who performed a comprehensive chart audit of the nursing documentation for all veterans on our unit. The audit revealed that some veterans had prolonged intervals between nursing documentation entries in CPRS. These findings highlighted an urgent need for educational initiatives aimed at our nursing staff regarding the importance of accurate and timely documentation, as well as a review of the required notes utilized in shift-to-shift reporting.
Following the audit, Angela and I organized several open forums to gain insights into the barriers staff faced regarding documentation. Staff members indicated that their limited understanding of documentation processes was a longstanding systemic issue within the unit. Areas needing improvement were identified from admission to Caribou, through CPRS, to BCMA. A rapid cycle of education commenced in early August and continued through mid-September, during which staff demonstrated full engagement, sharing their knowledge and best practices. We identified subject matter experts who graciously agreed to hold several educational meetings to ensure the staff had all the tools to be successful. We observed that team collaboration fostered accountability and support among staff. During the second round of open forums, staff indicated that a lack of documentation stemmed from uncertainty about the timelines for weekly and monthly assessments and reassessments, particularly in the context of rolling admissions. Consequently, leadership and staff determined that establishing a designated day each week for all assessments and a specific day each month for all reassessments would ensure 100% compliance. This approach facilitated accurate auditing and enhanced the assessment of documentation compliance, leading to targeted re-education. A rewarding highlight of this quality improvement process was when staff recognized that improved and consistent documentation in Veterans’ charts enhanced continuity of care. One staff member remarked, “I am able to be more efficient because of previous documentation, I don’t have to spend so much time figuring out the care I need to provide, its right there for me.” Each Friday, the leadership team shared our initial audits from July 2024, which indicated an average compliance rate of 35%. We highlighted these results in red and displayed them in our huddle room. Week by week, with completed audits, staff enhanced their documentation efforts, transitioning the metrics from red to green. The ongoing engagement between staff, the team leader, educator and unit manager fostered open communication, ensuring that nursing staff had the resources necessary for their success. Our audit compliance rates steadily improved; and on October 11, 2024, we achieved 100% compliance in all documentation. On October 15, 2024, we received an unexpected visit from Asselon for a survey, which ultimately resulted in zero findings or recommendations. During several discussions with the surveyors, they praised our continuity of care documentation as exemplary. In the exit meeting, the surveyor mentioned that throughout her 30 years of experience, she had never conducted a survey without any findings. I acknowledged that this achievement is a testament to our team's hard work and dedication. They have consistently raised the bar, surpassing their own expectations to deliver exceptional results for themselves and our veterans. I believe that this team consistently exemplifies the ICARE values in our daily activities, enabling us to achieve the organization's objectives while ensuring the well-being of our veterans.
By October, RN and LPN staff were completing all required documentation! This is the documentation that the surveyors were able to review for our survey.
Following the audit, Angela and I organized several open forums to gain insights into the barriers staff faced regarding documentation. Staff members indicated that their limited understanding of documentation processes was a longstanding systemic issue within the unit. Areas needing improvement were identified from admission to Caribou, through CPRS, to BCMA. A rapid cycle of education commenced in early August and continued through mid-September, during which staff demonstrated full engagement, sharing their knowledge and best practices. We identified subject matter experts who graciously agreed to hold several educational meetings to ensure the staff had all the tools to be successful. We observed that team collaboration fostered accountability and support among staff. During the second round of open forums, staff indicated that a lack of documentation stemmed from uncertainty about the timelines for weekly and monthly assessments and reassessments, particularly in the context of rolling admissions. Consequently, leadership and staff determined that establishing a designated day each week for all assessments and a specific day each month for all reassessments would ensure 100% compliance. This approach facilitated accurate auditing and enhanced the assessment of documentation compliance, leading to targeted re-education. A rewarding highlight of this quality improvement process was when staff recognized that improved and consistent documentation in Veterans’ charts enhanced continuity of care. One staff member remarked, “I am able to be more efficient because of previous documentation, I don’t have to spend so much time figuring out the care I need to provide, its right there for me.” Each Friday, the leadership team shared our initial audits from July 2024, which indicated an average compliance rate of 35%. We highlighted these results in red and displayed them in our huddle room. Week by week, with completed audits, staff enhanced their documentation efforts, transitioning the metrics from red to green. The ongoing engagement between staff, the team leader, educator and unit manager fostered open communication, ensuring that nursing staff had the resources necessary for their success. Our audit compliance rates steadily improved; and on October 11, 2024, we achieved 100% compliance in all documentation. On October 15, 2024, we received an unexpected visit from Asselon for a survey, which ultimately resulted in zero findings or recommendations. During several discussions with the surveyors, they praised our continuity of care documentation as exemplary. In the exit meeting, the surveyor mentioned that throughout her 30 years of experience, she had never conducted a survey without any findings. I acknowledged that this achievement is a testament to our team's hard work and dedication. They have consistently raised the bar, surpassing their own expectations to deliver exceptional results for themselves and our veterans. I believe that this team consistently exemplifies the ICARE values in our daily activities, enabling us to achieve the organization's objectives while ensuring the well-being of our veterans.
By October, RN and LPN staff were completing all required documentation! This is the documentation that the surveyors were able to review for our survey.