Partner Project Profiles

Grey Bruce Health Network

Grey Bruce Health Network is a network of 3 hospital corporations, a total of 11 small, rural hospitals in Southwestern Ontario, including one regional centre. The Network partnered with Open Source Order Sets (OSOS) in March 2007 and began their order sets project. Timelines were tight initially to get as many order sets built as possible, due to a concurrent electronic health record (EHR) build project that had strict deadlines. The Network had 150 existing corporate order sets to start from, and began the project with the conversion of these order sets.

In the first two months of the project, the order set Committee was formulated, and processes for development and approvals were approved across the corporations. The standardized template was created by the second month, and conversion of the legacy sets began. The Committee determined that they preferred the method of upgrading content prior to releasing any order sets on the website, in order to keep credibility, reduce confusion to users, and ensure that all order sets released were of the best quality. The preferred choice also for printing was print-on-demand, so all users across the sites print order sets directly off the OSOS website, except in very high volume areas and in ORs, where small volumes could be printed at a time.

By May 2007, the first order sets were released for use. The committee and development teams worked very hard, and by August 2007, over 60 order sets had been converted to the new format, content upgraded, and aligned with the EHR project to be built into the EHR software. At that point the committee slowed down, since the EHR project deadlines had passed, and were able to finish an additional 14 order sets by the end of 2007.

In December 2007, a change managmenet process was released to all hospital sites, along with a change request form to finalize changes to order sets. An audit was also completed at this point on the projects education and communication about the project, indicating that staff was fairly satisfied with the various methods for communication and education, which included inservices, online web-based learning, paper-based learning, newsletters, memos, and in-person informal education.

In Janauary 2008, the first usage audit was completed for the project. The audit looked at usage of the first 20 ordersets released, between one and five months after release, for a three month period October-December 2008. On average, across the Network, usage exceeded the benchmark provided by OSOS of 40% usage, reaching 44% usage across the hospital sites. There was large variation between the hospital sites, with two out of the eleven sites not using the order sets at all, but others reaching 77-81% usage. There was also a higher usage of surgical order sets (57%) vs medical order sets (28%). Overall the order set committee was satisfied with the initial audit, and is now undertaking a review of order set usage pre-implemenation, since all of these order sets were in use before the program, with corporate format and content.

Next steps for this project are to continue developing new order sets, now that over 95% of existing legacy sets have been converted. Departmental requests are now coming in regularly for new order sets to be developed. The go-live for the EHR is June 2008, and the project will evolve with the release of the electronic version of the order sets. In addition, some evaluation metrics will be developed this year, starting to measure outcomes of the new order sets that are now being used. Finally, the committee will also develop strategies to increase awareness and improve usage, beginning with the February 2008 release of a poster listing all order sets in use that will be posted on units, in ERs and in physician lounges.

Author: Jessica Meleskie
Coordinator, Evidence-Based Care Program
Grey Bruce Health Network

Halton Healthcare Services

Halton Healthcare Services (HHS) is an innovative and progressive, multi-site healthcare organization that provides quality health services to more than 300,000 Halton- Peel residents through its three community hospitals- Georgetown Hospital, Milton District Hospital and Oakville-Trafalgar Memorial Hospital. The staff and physicians at HHS take pride in the compassionate hospital-based health services that their hospitals provide to their growing communities. Although Halton is a small organization it is not naïve to the concept and benefits of order sets. Currently HHS has a total of over 150 across its three sites.

During the negotiations with Open Source Order Sets (OSOS) physicians and clinicians from across the three sites were provided with an overview of the project and a vision for the future of embedding best practice into the well established physician ordering process. OSOS received a resounding endorsement from those stakeholder groups and their enthusiasm for the project was well supported by the Senior Team. The contract was formally signed in April of this year.

With a new Hospital on the horizon slated for a 2013 opening the partnership within the network is timely. HHS joined the OSOS network to gain access to Canadian best practices and the clinical content of existing order sets, including specialty content order sets, Sylvia Rodgers, Chief Nursing Officer and Professional Practice Leader. Our collaboration with OSOS will ease and speed up our in-house order set development time. It will also provide access to a web-enabled repository for housing HHS approved order sets. Where we see tremendous value is in facilitating standardization that will enhance quality across our three hospitals and will ultimately improve patient safety, concludes Mrs. Rodgers.

A newly established HHS Order Set Committee was launched in May 2008 and has been instrumental in driving this process forward. Dr. Sanjay Pandeya is the physician Co-Chair of the HHS Order Set committee and in collaboration with the Chief of Staff, Dr. Lorne Martin are the physician ambassadors for the project. Their sentiment? Quite simply, a great idea thats time has come.

Author: Joan Jickling RN MN
Professional Practice Coordinator
Halton Healthcare Services

Toronto East General Hospital

Toronto East General Hospital is 537 bed, community teaching hospital serving southeast Toronto, Ontario. TEGHs eChart Plan, in partnership with the Ministry of Finance and Ministry of Health & Long-Term Care, is to achieve a 95% electronic patient record by 2010. Within that scope, the organization is aiming to implement computerized provider order entry (CPOE) and an electronic medication administration record (eMAR) by March 2009. We are using a Cerner Millennium system for this project.

Currently, the hospital is making use of approximately 150 preprinted order sets and protocols, primarily in 3-4 health service programs. In order for CPOE to be an efficient and user-friendly process, order sets should be created for all admissions and covering as many procedures and ongoing treatments as possible. All physicians and clinical staff have been informed of this need and have been recruited to participate. The original target of 300 major order sets has now risen to 474 proposed sets (including smaller modules). To facilitate this development process, TEGH has joined the OSOS network to gain access to Canadian best practices and clinical content of existing order sets. Physicians and staff are using this site as a starting point to create new order sets or revise their existing ones.

TEGH has established specific guidelines for order set development, including ensuring that a core team, comprised of a physician, nurse and pharmacist, reviews each set, followed by Program council and Pharmacy committee approvals. During the development, there is also collaboration between the informatics team and clinical areas to facilitate design of the sets. Project working groups are also developing organizational standards for design, terminology and module content. Once approved, the informatics team will build the plans electronically, then review and revise with the clinicians until satisfactory.

Collaboration with OSOS is facilitating not only the clinical content development, but greatly supporting the administrative work required for producing these sets. TEGH is progressing towards establishing a successful electronic order entry system and thereby, ensuring excellent patient care.

Windsor Regional Hospital

Windsor Regional Hospital is a large multi-site health service organization serving a population of 400,000 people in Windsor and Essex County. Established in 1994 following a merger of Windsor Western Hospital Centre Inc. and Metropolitan General Hospital, Windsor Regional Hospital provides over 174 years of combined history in health care services. Providing Acute and Continuing Care Services with 716-beds on various sites, Windsor Regional Hospital is one of the largest non-teaching hospitals in the Province of Ontario.

In 2007 Windsor Regional Hospital joined the Open Source Order Set Network with the support of its Medical Advisory Committee and Hospital Board of Directors. Through membership we hoped to gain access to resources, best practices and order sets from across Canada as well as the support we required for process improvement in paper order set development, and implementation as we prepare for our electronic provider order entry build.

Over the course of the last year we have gained invaluable support and guidance from OSOS in this regard. One of the first and most time intensive tasks was cataloguing our current order sets, which were on various templates and in multiple formats. The OSOS was extremely helpful in converting our “legacy” sets into our new standardized template.

We kicked off our new order set development process in January of 2008 with an event attended by our staff and physicians and our senior leadership team. We struck interdisciplinary development teams led by nursing and physician champions based on patient population. Their first task was to review all of our current order sets for relevance to current practice and opportunity to improve the care being provided with inclusion of best practices and evidence based medicine. No small task and our teams are to be commended for their work in this regard. Access to order sets from across Canada saved much time in this regard, and the linkages with contacts through the OSOS was extremely helpful in answering the many questions we had from our teams during the early phases.

Windsor Regional was one of the first Hospitals to introduce patient quality and safety indicators publicly. These include Hospital Standardized Mortality Ratios (HSMR), Hospital acquired infection rates, patient and staff satisfaction and financial performance. We have utilized our patient quality and safety indicators to help prioritize development and incorporated many improvements into our newly developed order sets, including best practice guidelines, Safer Healthcare Now care bundles, ISMP and FDA recommendations, as well as triggers for alerts for specialized populations that we serve such as the frail elderly and the neonate. We trialed our newly developed and templated orders in May of 2008 on our Pediatric Clinical Teaching Unit with great success and have begun our corporate spread.

Throughout the past year we have already seen the effects of implementation of these best practices including reduction in inappropriate antibiotic use, decreased infections and improved compliance with SHN (VAP, CLI, SSI), and increased completion and usage of order sets. We have been able to archive a number of outdated order sets, developed new order sets and combined multiple order sets into single order sets. The implementation of the OSOS online printshop ordering and training of staff to utilize the print on demand function both have improved physician and staff access to order sets in a timely manner, and reduced storage required of less frequently used order sets.

We have partnered with Hotel-Dieu Grace Hospital, who are also OSOS members, and together have developed a number of integrated order sets, with a goal of standardizing and improving practice at both facilities, and making it easier for our physicians who practice at both institutions with the availability of the same order sets.

We still have a long way to go with our order set development, with a goal of over 400 order sets but we have also come a very long way in just a few months. Through the support of OSOS and the engagement of our hospital staff we will meet those goals without a doubt. As our hospital vision statement declares Windsor Regional is committed to providing Outstanding Care - no exceptions!

Author: Karen Riddell, RN, BScN, MBA

QUEST for eCare Project Manager

Windsor Regional Hospital