Today’s healthcare organizations are placing increased emphasis on expenditure control and cost reductions. In a typical hospital environment, human resources represent approximately two-thirds of expenses (Fottler, Hernandez, Joiner (1994) p. 167).   In response to external market forces during recent times, healthcare organizations have reduced their human resource budgets, including clinical staff, to levels that support only   the tasks required to provide patient care.  Healthcare organizations are being driven to work smarter and more efficiently and must do everything possible to improve the efficiency of their employees and control other expenses.

        It is abundantly clear that one way in which organizations can improve the efficiency of their employees is through the use of technology.  It is also clear that  “Automation offers many solutions …  that allow the nurse to work more efficiently, allocate resources more effectively, and improve client care” (Hebda, Czar, Mascara, 1998, p.3).    Most healthcare organizations have a technology infrastructure in place to support patient management and finance functions. Lately, most modern healthcare organizations have invested heavily in automated systems in support of its departments with the exception of the Nursing Department. However, these applications have little impact on the accessibility of information to the bedside clinical nurse. Commercial software developers have not created applications to support the Nursing Department’s vital need to communicate to its working professionals and provide nursing-specific information such as policy and procedure documents in an organized and efficient manner. The technology to support these communication needs is currently available in most healthcare organizations, but it is under-utilized, primarily because the individuals who control this technology are unaware of Nursing’s communication and informational needs and of the environmental and practice specific restrictions related to the clinical setting of the bedside nurse.

        The implementation of automation in support of Nursing’s communication needs can take many forms. In the remainder of this article, the author describes the project and process that led to the creation and implementation of an intranet-based technology tool devoted entirely to the Nursing Department’s communication needs.

 Assessment

         The initial scope of the project was the development of a method to convert into electronic format the paper-based policy and procedure manuals of a community-based hospital’s Division of Nursing. The existing paper-based format for these manuals required that each nursing unit have a minimum of three, five-inch binders containing the Division of Nursing’s Policies and Procedures along with the Departmental Plan for the Provision of Care. Some of the shortcomings of this paper-based approach were that the binders required were heavy, cumbersome, and difficult to maintain since pages were often removed and not replaced.  This resulted in information not being easily available or current when needed.  The paper-based approach was also a drain on the organization’s resources because whenever a new policy or procedure was written or an existing document was updated, each new document had to be duplicated and inserted into the proper manual in each of the 15 locations the manuals were kept. The author believed that converting these documents to an electronic format that could be made available through networked personal computers at each nursing station would eliminate the problems associated with the paper-based approach and make these documents more accessible to nurses in their clinical work areas.  

        Initially, the author anticipated setting up a common hard drive on one of the organization’s network servers to hold all the electronic policy and procedure documents, which were at that time written in Microsoft Word ^â.  A method then would need to be developed and implemented to facilitate accessing those documents from the multiple PCs located on each Nursing Unit.   In light of the fiscal constraints facing the organization, it was necessary to find a method that would enable ease of accessibility without adding considerable additional costs.  This requirement prohibited the installation of specific application software on each PC because of the prohibitive additional costs associated with an additional 20+ end user licenses. 

        While reviewing the literature for potential technologies to implement as a solution to the process of converting paper documents to an electronic format, the author became aware of the concept of “intranets.”   “Intranets are networks that are accessed using a web browser but are only available within a specific organization. They are useful in making information that is needed by those within an organization freely available” (Thede, 1999, p. 2280).  According to Hebda et al, “Intranets are private computer networks that use Internet protocols and technologies, including Web browsers, servers, and languages, to facilitate collaborative data sharing” (Hebda et al., 1998, p.65). “Web technologies promise to help unblock the information flow, redesign business processes, and improve productivity for all users” (Intramark, 1999). “Companies that have invested in an intranet are finding great benefits in reducing the cost of paper document distribution, increasing communication, and improving access to current information” (Microsoft, 1999).

An intranet, or internal web site, offers many and distinct advantages to users.  Habda et al., (1998, p.66) indicate that an intranet:

      ·    Can provide for the paperless distribution of internal documents    

      ·    Permits rapid retrieval of information 

      ·    Is easy to use

      ·    Provides users with a familiar user interface requiring little training

      ·    Provides inexpensive access to corporate data

      ·    Is relatively in expensive to implement  

      ·    Provides support for multi-platform integration

      ·    Fits well with newer client server architecture 

An intranet appeared to be an ideal infrastructure for Nursing to use to improve communication and efficiency through automation.  The use of this technology would enable Nursing to communicate quickly and efficiently and also control the materials costs associated with a paper-based approach.  

Planning

        Once the decision was made to focus on the development and implementation of an intranet, it was necessary to identify what specific technology would be employed to carry out the project. The two technology approaches considered were document conversion to Adobe Acrobat® format and document conversion to HTML format.

        The use of Adobe Acrobat® as a conversion methodology would require the purchase of Adobe Acrobat® and the installation and maintenance of the Acrobat Reader® on all the facility’s desktop PCs. Additionally, a distribution methodology such as a shared network hard drive arrangement would need to be developed.

        The second approach considered was to convert all paper documents to HTML (Hyper Text Markup Language) and to develop and implement a web-technology- based delivery system. Both solutions provided similar characteristics throughout the conversion process as well as maintaining the security and integrity of the documents. However, the HTML conversion process had the following additional benefits over Acrobat Reader Ò: lower cost, a more familiar end-user interface, no additional end-user software to be maintained, and most important of all,  the ability to easily expand the project to encompass the delivery of other vital Nursing information beyond electronic policy and procedure manuals. By employing HTML conversion technology, it would be possible to develop a full intranet devoted to the present and future communication needs of the Division of Nursing well beyond the dissemination of electronic policies and procedure manuals. Once the underlying technology was chosen, Microsoft Front Page 2000® was purchased. This application is a web site designer as well as an HTML editor. As the author had never undertaken an endeavor such as this, a few weeks were needed to become familiar with the application software and to develop the structure of the soon-to-be-constructed “web.”   

Implementation

        The implementation phase began with the design of the basic structure of the intranet or internal web site.   Initially the web site was designed with a simple structure consisting of a home page for users to use as a starting point and six additional pages to be used for index pages. The index pages would provide the links to the converted documents.

        The second step in implementation was conversion of the approximately 180 Nursing policies into HTML by using the “save as HTML” command within Microsoft Word 2000®.  Following the HTML conversion process and the creation of the hyperlinks between each index page and its associated documents, an external person knowledgeable in the construction of web sites conducted a review. This review revealed faults within the design of the navigation structure that would impact on operability by a novice level user.

        Based on this feedback, the web site’s organization was re-designed in a more hierarchical structure with a more formalized parent-child page relationship. This more formalized web site structure resulted in the creation of a home page for the intranet.  This change also resulted in the need to insert a page into the basic web for each document that would be included. Once the 200 additional pages were inserted into the web site within the new hierarchal structure, the process of converting each structure standard (policy) into HTML and importing the converted document into its designated page was initiated. This change in design structure allowed for the Front Page 2000® application to combine into one process the process of conversion into HTML and insertion into an individual web page. Upon completion of the conversion / insertion process, each new web page required formatting adjustments to correct any errors generated by the conversion as well as to standardize document formatting.

        The next part of the project implementation encompassed the creation and testing of all the hyperlinks between the home page, the index pages, and the individual document pages. At this point in the project it was also necessary to develop a method to import and link additional supporting documents into the web’s structure. These documents were often forms or flowcharts related to the policies or procedures.  Since the process of conversion to HTML format did not maintain the formatting of the original documents, especially forms; it was necessary to scan these additional documents into a graphic format. These documents, now converted to graphic images, were then linked by hyperlinks to the policies they supported. This process maintained the formatting of the documents as well as the general navigation structure of the intranet as a whole.

            Based upon the work already done, it was decided at this time to expand the intranet into areas beyond the project’s original scope of creating electronic manuals. The project was now beginning to take advantage of the expandability inherent within the creation of an intranet.   Within the intranet, areas were created for the soon-to-be-released Clinical Practice Guidelines for the Division of Nursing and for materials to support staff and patient education. An area was also created for electronic distribution and archiving of the Division of Nursing’s quarterly newsletter.

         Additionally, a tutorial was created and included on the intranet’s homepage which described the intranet concept and provided directions on how to navigate through the intranet for those not familiar with web surfing.  The tutorial was created using Microsoft PowerPoint 2000^â  which allowed for the tutorial to be saved as a web page and viewed within a web browser without the need for installing additional application or viewer software. The completed intranet, the organization’s first internal web site, was installed on a dedicated web server set up by the hospital’s Information Systems Department.

        The last step in the implementation phase was to introduce the intranet and train users.  A series of “Welcome to Your Intranet” parties were held for the Division of Nursing staff. These parties consisted of ten events totaling 16 hours spread over two days and on all shifts. This allowed the staff to see and have a hands-on experience with their new intranet.

Conclusion

        The development and implementation of this intranet project were successful. The initial intent of the project, the creation of electronic policy manuals, has been achieved and surpassed by the creation and installation of a fully functioning intranet or internal web site devoted to the Division of Nursing.  As pictured in Appendix A the clinical bedside nurse now has full access to a dedicated internal web site that contains information in the following areas: Polices, Procedures, Clinical Practice Guidelines, Staff Education, Patient Education, and the departmental newsletters.  Reception by staff who attended the welcome parties was positive and generated much discussion as to potential future enhancements to their intranet.  While the roll out of the intranet appeared to be well received by the nursing staff initially, as with the introduction of many new technologies of this sort, actual utilization of the intranet site as a communication tool was low in the beginning.  As many of the Division of Nursing’s departments such as the Department of Education and Professional Development as well as the Wound, Ostomy, Continence Nurse and the Oncology Clinical Nurse Specialist have begun using the intranet as a primary means of making information available for use in both staff and patient education undertakings the staff’s usage patterns have slowly but steadily increased over the past six months.  This information can now be easily accessed from any desktop within the facility as well as at the bedside once RF (radio frequency) wireless technology is implemented.

        While this project was initiated in response to the author’s desire to improve the Nursing Department’s communication with its professionals and increase the accessibility and ease of use of information for nurses by nurses, future development and enhancement of the intranet will be incorporated in response to suggestions from the bedside nurse.