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Many hospitals have so many policies and procedures that are important to their organization. None of them are as important as clinical order sets, but it can be difficult to get the latest version of so many documents into the hands of so many people. We know how important this is because research shows the implementation of clinical order sets improves compliance with recommended standards of care and ultimately improves patient outcomes. Here at PolicyMedical, customers often ask us the best way to manage clinical order sets. For this reason, we have written this article to discuss the best practices around clinical order set management. Once you have reviewed them, you will be able to determine for yourself if these practices might apply to your own organization.
What is a Clinical Order Set?
A clinical order set is a pre-defined template that provides support in making clinical decisions for a specific condition or medical procedure. It is a grouping of orders that standardizes and expedites the ordering process for a common clinical scenario. Clinical order sets guide clinicians while treating patients to ensure that they do not miss any critical components of care. The following best practices will help you in selecting and implementing a clinical order sets management system.
Sample Template for Clinical Order Sets in PolicyManager6
Choose a Cloud-Based System
Hospitals have utilized clinical order sets for many years. In the past, they were created and stored on paper. However, with the recent passage of various standards and regulations, it is increasingly important that they be maintained electronically. Cloud-based clinical order sets allow health care organizations to have a highly accessible system without extensive IT demands. Clinicians can utilize the system from any location through any device, including mobile devices and tablets. Updates are immediately reflected throughout the system.
Format Order Sets Efficiently
Clinical order sets can range widely in complexity. For maximum efficiency, clinical order sets should:
- Have a standardized format that is easy to understand.
- Be built with evidence-based practices.
- Contain all necessary information required to complete the clinical order set.
- Automate only those features that are absolutely necessary.
- Prompt for all necessary information.
Example of a Clinical Order Set with formatting that is clear and easy to read.
Collaborative Development
Effective clinical order sets should be developed by a multi-disciplinary team of clinical experts, using the most current medical evidence. Key clinical leaders, department heads and other physicians should be directly involved in the process in order to provide input and relevancy for various specialties. In a large multi-site hospital where busy clinicians must come together in a central location, this process can be very difficult, but it is imperative. Including a pharmacist and a representative from the nursing team is useful to ensure that clinical order sets meet pharmaceutical guidelines and will align with nursing processes.
Regular Maintenance
Once clinical order sets are established, they must be regularly reviewed and updated, which can be a challenging process. Medication guidelines change regularly and research forms new best practices for treatments. If there is a mismatch between a current document and an earlier version, it could lead to significant patient safety errors. It is a key best practice to have an assigned point person to monitor any new information and incorporate it into current clinical order sets.
Monitor System Usage
Relevant data entered into electronic clinical order set systems should be captured and made available for analysis. This will track systematic trends and give valuable insight into utilization of the system as well as overall patient care. If utilization of the system is lacking, or if organizational goals are not being met, your clinical order sets team should meet to re-evaluate the system and find a way to improve it.
Helping Hospitals Ensure Patient Safety
Increasing the use of clinical order sets is important in all clinical settings: from acute care hospitals and long-term care homes, to continuing care organizations and other areas of the health care spectrum. By helping clinicians complete each intervention safely and in a standardized manner, they ensure patient safety and mitigate risk. In addition, the implementation of clinical order sets is an important step in compliance with the Center for Medicare and Medicaid Services meaningful use and Joint Commission core measures. At PolicyMedical, we created PolicyManager to help you select and implement the best clinical order sets management system for your healthcare organization. We understand that no system is perfect for everyone, but if you would like to see a demonstration of our clinical order sets solution, click here to request a consultation with Bailey or Ismail.
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