TL - Transformational Leadership

TL4EO: Advocacy and Influence. Describe and demonstrate (1) CNO influenced organization-wide change


The required format for EO sources of Evidence (page 52 of 2008 Magnet Manual)

A CNO-influence organization wide change was not demonstrated

  • No pre and post initiative data were presented


  • Required format used
  • Pre and post data provided


The Implementation of the Electronic Medical Record (EMR) at Jersey City Medical Center has many implications for nursing practice and workflow. Leading this tremendous task is Rita Smith DNP, RN, NEA-BC, Chief Nursing Officer, who functions as the Executive Champion for this Project. One of Ms. Smith’s main goals during the implementation of the EMR was to ensure that JCMC achieves “Meaningful Use” criteria as established by the Department of Health and Human Services (HHS).

2012-2014 Health Information Technology (H.I.T) Timeline

2012-2014 Health Information Technology (H.I.T)Timeline

One main organizational wide change influenced by Ms Smith was the implementation of the electronic problem list via the new Siemens Soarian EMR system. The problem list plays a significant role in improving patient care at JCMC. Nurses use the problem list to develop individualized plans of care to guide assessments, evaluate diagnosis, and identify patient outcomes. This list is used to indentify and prioritize the patient’s main problem(s) so that all members of the healthcare team can view at a glance all the issues from a multidisciplinary perspective.

Previous to EMR implementation the problem list was documented on paper. This method is inconsistent and allows for variability in nursing terminologies across the continuum of care. In addition, due to this manual process, it is often difficult to maintain a current problem list as patients conditions change, or they are transferred to other levels of care. Ms. Smith recognizes the need to have an accurate and functional problem list for nursing.

The electronic patient’s problem list is one of the required data elements for stage I of “Meaningful Use”. Please refer to the Health Information Technology timeline (TL4EO-A) and Attestation Work sheet (TL4EO-B) for the “Meaningful Criteria”. In order to meet these criteria the problem list must be up-to-date with “current and active diagnoses” stored as structured data using ICD-9 codes or SNOMED CT code. Therefore, As of July 1st, more than 80 % of all patients admitted to JCMC’s inpatient or emergency departments must have at least one entry, or an indication that no problems are known in the patient’s electronic medical record.


  • Establish an electronic problem list that that promotes quality care across the continuum of care
  • Establish a process for maintaining a current problem list with standardized terminology
  • Meet the minimum requirements for stage I of “Meaningful Use” by July 3rd 2013
  • Increase compliance with the problem list to exceed 60%
  • Provide Education to all nursing staff


Ms. Smith established a project management team who assumed the responsibility of designing, implementing and providing education on the new electronic problem list. The team included the following individuals:

Participants Table


The coordination and development of the problem list began in November 2012. Christian Sanchez MSN, RN was the lead analyst on this project. The first step taken by the team was to rebuild the problem list in order to utilize problems that had associated SNOMED codes, which were needed for meaningful use. This process of designing, building and testing the problem list took approximately four months. Once completed, a comprehensive learning module was developed by the team and placed on JCMC’s online learning module (TL4EO-C). In February 2013 the education module was assigned to all nursing staff. A completion report of nursing staff that completed the learning module can be seen in TL4EO-D. On March 4th the problem list went live for all nursing units documenting in Soarian TL4EO-E. Screen shots of the problem list in Soarian are available in TL4EO-F. In order to increase compliance and facilitate ease of use by the nursing staff, the problem list chapter was built into the admission and shift assessment. On April 17th a complex rule was implemented that suggests problems for the nurse to add based on their documentation. Since the learning module was published, nursing documentation on the problem list improved steadily as the project management team made improvements.


Previous to March 4th 2013, the problem list was documented through paper charting. It was important to Ms. Smith to obtain a baseline audit of the problem list across the continuum of care. Therefore, the Critical Care Division was chosen for review due to the complexity of care that must be coordinated through different levels of care and health care providers. Random audits of patients in the critical care setting were reviewed during December 2012 - February 2012, to identify further areas of improvement needed. The data from this audit highlighted the need for an electronic up-to-date and standardize problem list that can be used throughout the continuum of care. Audits were only conducted for these three months, which was enough to demonstrate the desired improvement with the electronic medical record.

Pre-implementation data

Pre-implementation data 

Post-implementation data

Post-implementation data 

The results of this data reveal a significant improvement in the documentation of the problem list in Soarian Clinical Documentation System. An increase in compliance with the use of the problem list exceeded 60% by April 2013. In addition, this data meets the minimum requirement for meaningful use due July 1st 2013.