Tuesday, October 16, 2018

52 Clicks

During this past Friday’s Lean Daily Management rounds, I learned that a nurse doing a complete neurological check on a patient after spine surgery had to click 52 times in the electronic health record to document his or her assessment. I was stunned by this assertion. I have been very concerned about creating unnecessary work for our nurses who already work so hard. This example made me concerned that in our zeal to get to high reliability (what should happen happens and what should never happen doesn’t) by creating standard work, perhaps we had created a system that is not sustainable.

Checking on the neurological status of a patient who has just had spine surgery is very important to make sure that we do not miss a serious problem in the making. Documenting our check is important to our colleagues, in this instance especially the operating surgeon, can see the result of our neurological exam. But does it have to be so hard?

Before the reader races to blame the electronic record let me point out that the paper world left room for error as well. With a blank piece of paper, it was easy for the clinician to write Neuro: WNL, meaning the entire neurological exam was normal. This would always raise the question of whether an entire exam was done. We also had the problem of illegibility with some handwriting.

This is an instance where we healthcare leaders need to avoid the “either, or” trap. Either the documentation will be complete, or it will be efficient. We need “both, and” solutions that will allow for documentation that is both complete and efficient. Wouldn’t it be nice if as the nurse was doing the exam the documentation just happened? How about voice recognition software that would allow the nurse to speak the results of the exam as it was being done?

I am sure that we can come up with a system that would be better than the 52 clicks. Do you have an idea? Please share it.


  1. It would be very helpful if we were able to copy forward our own docuemnted Neurovascular assessments, as we are currently able to do for Neuro checks ordered every 4 hours. I know within Epic there is a functionality for this, which allows nurses to only copy forward their own assessments, and only those that were documented within the last 12 hours. I believe this would allow us to focus more on variances in a patient's condition, while drastically reducing the number of clicks we have to make

    1. Thanks so much for your input, Anonymous! I am not knowledgeable enough about what you are suggesting but please bring it up to your manager so that we can involve our Epic analysts in studying your idea.

  2. The number, 52, is neutral; it is neither high nor low. 52 is the number of cards in a deck; would it serve its purpose without all 52? There are 52 weeks in a year; compared to 365, 52 sounds low.

    Do we question the number 52? Or do we ensure each of the 52 clicks add value? LEAN Manufacturing defines ‘value’ as any action or process for which a customer would be willing to pay. If a click guarantees that every question will be answered, and answered accurately, versus removing clicks, and assessments being somewhat, nearly or almost accurate, I believe most patients would ‘lean’ toward the 52 clicks for spine surgery.

    Do End Users know the value of each click? Has the question of value been raised with the vendor?

    Is every path -- spine surgery and mole removal – equal? Or is spine surgery more involved, thus resulting in more clicks?

    Can that 52-click path be accomplished with 38? Are Best Practices and most efficient paths followed? Has training continued, or have skills stagnated?

    If 52 clicks are equivalent to The Masters’ world-class greens and users, do we want to be mini-golf?

    52 is literally just a number (or data) – with no inherent value (meaning). Let’s continue this dialogue to add value to the number of clicks, or change the number of clicks.

    Thank you.

    1. Thanks, Amy. You raise some very thought-provoking questions.

  3. I will define the 52 click for you in more meaningful terms. I just completed documenting a normal neurovascular assessment on a patient and it took me 1 minute and 45 seconds. Most of our patients that require NV checks, require them every 4 hours. So for each patient, over the course of a 12 hour shift, a nurse is spending at least 5 minutes 15 seconds documenting a NV assessment. I say "at least", because if it is abnormal, it takes more time and attention to document the details.

    It is possible at times on unit 58 that a nurse might have 5 patients over the course of a shift that require q4hr NV checks. That translates to AT LEAST 26 minutes and 15 seconds to document a NORMAL assessment.

    When you consider that amount of time spent documenting a neurovascular assessment in addition to all the other documentation, 26 minutes is a whole lot of time spent just trying to record a small fraction of our assessments that we complete on every patient.

    We want less screen time and more patient time. It would be very time saving if we could copy forward an assessment if it hasn't changed. And even if it has changed, all we would have to do is change the sections that have changed.

  4. Excellent, anonymous. Please discuss how we might do this with your nurse manager. Thanks!


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