St Joseph’s Continuing Care Centre Embracing technology one work order at a time

It’s 8pm, you’re working the night shift and Mr Donovan just came back from a shopping trip with his daughter. He’s pleased as punch that he’s now the new owner of four pairs of pants, 3 sweaters and a whole WalMart pack of white undershirts.

You’re not so pleased with the additional work you now have to do. Each new article of clothing needs Mr Donovan’s name labelled in the back and since the housekeeping staff have long since gone home, the task falls to you to gather up the articles of clothing and leave them a handwritten note stating whose clothes they are and what room they need to go back to.

Mr Donovan might be lucky to see his new clothes in a few days, that is if the Housekeeping staff doesn’t lose the message in the piles of other notes on their desk; if they do, who knows when Mr Donovan will get to wear that new sweater he was so proudly showing you.

Earlier in the day over in the maintenance department the maintenance manager was told there had been a problem noticed with a valve on the HVAC system in a recent inspection and that he’d have to take a closer look at it on the roof.

The manager sends one of his guys up to check it out and see what parts might need to be replaced. He’ll have to climb to the roof, write down the part numbers, and then climb down to call the manufacturer to see if it’s repairable and then see if their supplier has the part in stock before he can even do anything about fixing it.

A volunteer helping out in the dining room has noticed that Mrs Bickert is having trouble feeding herself. She’s supposedly been given exercises to help strengthen her hands. The volunteer mentions it to another one of the nurses who makes a mental note to mention it to the physical therapist the next time she sees her in the halls. That is if she remembers. The nurse has been having a hard time with her kids in the last little while and is preoccupied with a bunch of other things on her mind.

Mrs Bickert probably won’t have an extra conversation with the physical therapist about how the exercises will help her eat better, and the dinning room volunteer might never know if her concern was actually passed along.

In any type of senior care facility, public, private, not-forprofit, government funded, there are a multitude of people that rotate through the front doors on a daily basis. All with specific skill sets and jobs, but all with one singular purpose in mind, ensuring that the residents who live under that roof are cared for in a kind, dignified and respectful manner.

Each staff member is trained for an eye towards different things, all see different things but all of them need to communicate with the other staff members in the building to ensure that the residents’ quality of life continues. But how does a facility make sure that communication works in everyone’s favour?

St Joseph’s Continuing Care Centre in Cornwall, Ontario was faced with a similar problem and came up with a solution that has changed the way everyone who steps through its doors works and lives.

Four years ago, when the facility was moving into its newly constructed building, they knew it was the right time to also address how preventative maintenance and work orders were handled.

“We had to design a completely new preventative maintenance system from scratch,” states Tony Ingram, St Joseph’s Director of Support Services Manager, “and we were looking at alternative options.” “Most facilities have a completely paper based system,” states Derek Soares, St Joseph’s in house information technology manager, “and there are some electronic systems to facilitate preventative maintenance but they’re extremely expensive and most of them are way more complicated than what a long-term care home would need.”

“All the commercial preventative maintenance applications are designed for factories and have a lot of complex parts and motors and we just needed something simpler.”

So Soares, a computer science program graduate with a Health Informatics diploma from the University of Sherbrooke, wrote and customized the program from the ground up, a task that he worked on over a six month period whenever his workload would allow for it.

For the uninitiated, “preventative maintenance in simple terms is just really a set of scheduled work orders,” explains Soares, “so our thinking was why couldn’t we have one integrated system that would manage work-flow for our maintenance crew that would facilitate both requisitioning and work orders on the floor and preventative maintenance.”

While Soares worked on building St Joseph’s wireless work order system a stop gap electronic requisitioning system was put in place, “but what was happening,” explains Soares, “was it would print out automatically on a printer in the maintenance shop and the guys would pull the papers off the printer. It was also really inefficient.”

Creating your own work order and requisition system takes time and some money. St Joseph’s switched over to the fully electronic system just over a year ago, but the benefits are already being felt.

“We’re doing approximately 250-300 work orders a month,”

states Ingram, “which works out to around 4,000 work orders a year.”

Ingram points out that it is difficult to measure the impact of this system because with the old paper-based one, “a lot of times... the guys would physically sign off on a ticket and stick them in a filing box and we weren’t necessarily back then writing down when the ticket was resolved in terms of the time.”

The program which was initially started strictly for maintenance has now been expanded to include other sections of the care facility.

Being the predominant group creating work order tickets, nursing got so comfortable using it that they started asking for a similar program. “They wanted to know why they couldn’t requisition therapies or dietary in the same way,” states Soares, “and so we started slowly rolling out an updated version for them to use.”

“Basically the problem we had before we started using this system,” notes Soares, “was that if you were an occupational therapist, physiotherapist, a speech therapist or dietician or any other person providing a service through out the home you were getting voice mails and e-mails about residents, plus getting notes on their desk,” he continues, “and then they’re getting stopped in the hallway and being asked to do things while they’re walking around.”

“There was no way to know for sure that what you were requesting was actually happening,” remarks Soares. “If you’re a nurse and you leave a voice mail for physiotherapy to reassess somebody, if you don’t have a work order system you’re hoping that it gets done, or you probably have to look in the chart, you wouldn’t really have that closed loop.”

Now with the new system in place a nurse can get a feedback email whenever the time is closed even if they’re not working that day or if they only work on weekends. “You get that closed loop on every single requisition,” states Ingram, “so there’s no more phantom tickets or people wondering if something was taken care of.

Since nursing is the predominant group creating work order tickets and requisitioning the rest of the multi-disciplinary team, a concerted effort was made to make the requisition process as simple and as fast as possible.

“We have an icon on the desktop of every computer in the facility,” states Soares, “so a nurse at every one of the computers that they would have access to, can just double click on the icon and enter their name, email, the ticket description and then pick the department that it goes to.”

“So now a nurse creates a ticket in real time at 7 o’clock in the morning that says ‘please fix Mrs Smith’s wheel chair’” notes Ingram, “and they requisition the physiotherapy department, the physiotherapist can be walking around on the floor get a notification that a ticket has been created, and they can immediately go right there, fix it, close the ticket at the point of service and then the nurse automatically gets feedback that the problem has been looked after,” he remarks.

The facility also then has a statistical start date and time and an end date and time for that ticket, information that can then be stored in a database to help analyze where problems occur most often and can even translate into better planned and more accurate budgeting.

Notes Ingram, “basically the direction for us is that everything goes through the work order system. So if somebody stops you in the hallway to pass along information you just tell them to fill out a work order,” something he says was a bit of a learning curve at first but now there are no issues with it.

Finger pointing and blame games are a common thread in a lot of long term care facilities, but with the work requisition and preventative maintenance program staff, morale and job satisfaction has seen a big improvement.

“From the nurses perspective they know that there’s going to be 100% resolution to the issue even if the result is ‘no we’re not going to do this and here’s why,’” says Soares, “they know that they’re not being ignored.”

Ingram points out that the program can also be helpful in WSIB cases: “we’ve had situations in the past where someone claimed two work orders had been produced with no resolution before the case occurred, and in the old paper-based system we were looking back through years of paper work by hand, to find if those work orders were ever submitted.”

With the new electronic work order ticketing program all it would take is a quick search through the archives to uncover if or when the work orders had been submitted. Although Ingram is quick to point out this is not the intent for which the program was initially designed, it has proven to have some unanticipated added benefits.

The program has also worked so well that at the latest board meeting Soares heard that the physicians’ group is now asking to be brought on to the program and there are hopes that social workers will be added in the near future.

“We may have to make some changes to the program so these added groups can work with it, but we’ve got a great vision for the future,” remarks Soares, “it could be developed for any aspect of our facility.”

Soares and Ingram are both quick to acknowledge that St Joseph’s solution is not necessarily going to be the answer for all senior care facilities and encourage others to strike out and find either an off the shelf system that can be adapted to fit their needs or investigate ways to build their own custom system.

In terms of the technology needed to run such a program Soares says that there was a substantial initial investment in the neighbourhood of $50,000 into the wireless infrastructure and both Soares and Ingram emphatically state that this was the best purchase that St Joseph’s could have ever made.

Currently all medication carts are equipped with a ruggedized Lenovo laptop and barcode scanning capabilities for the electronic administration of medication. St Joseph’s also invested in 10 iPod Touches and hope to add five more by the end of this fiscal year.

The iPod Touches have allowed the facility to get rid of their phone system which was similar to Spectralink, a wireless phone integrated into the telephone system, allowing staff members to move around the facility but still stay connected to their phone lines.