Delivering high quality documentation on operative consent forms: a UK major trauma center Quality Improvement Project

Abstract

Background: Royal College of Surgeons guidelines exist on the importance of full, accurate and legible completion of consent forms as a key part of the process of gaining informed consent. In addition to this, consent forms serve as an important medico-legal document to protect clinicians and patients should problems arise. It is therefore in all parties’ interests that they are correctly completed. It was noted that consent forms within the Royal London Hospital Plastic Surgery department were often not correctly completed. A Quality Improvement Project was undertaken to improve the completion of consent forms within the department. Materials and methods: Common problem areas on consent forms were identified and Quality Improvement (QI) methodology was used to design the study including selection of appropriate outcome, process and balancing measures. Baseline information on completion of: (1) patient details, (2) consultant details, (3) legibility, (4) use of abbreviations in description of operation/complications, and (5) patient signatures was collected. Four weekly interventions were made which were accompanied by 4 further data collection cycles. A further reaudit took place 4 months following the completion of the project to establish whether improvements had been sustained. Results: Over the 5 QI data collection cycles the average completion of the 3 outcome measures rose from 59% to 93% and 4 months later was sustained at 91%. Outcome measure 1 (legibility of documentation) rose from 62% to 100%. Outcome measure 2 (omission of abbreviations) rose from 33% to 79%. Outcome measure 3 (patient signature) rose from 81% to 100%. Conclusion: This Quality Improvement Project led to a significant and sustained improvement in quality of completion of consent forms within the department with the most marked improvement in omission of abbreviations. This quality improvement methodology could easily be adapted for other surgical specialities.