The effect of implementing a standardized process on the quality of discharge summaries

Abstract

Background and objectives: To assess the compliance rate and overall quality of discharge summaries according to JCIA standards among King Faisal Specialist Hospital and Research Centre (KFSH&RC) patients over a three-year period. Patients and methods: A multidisciplinary team consisting of the: 1) Quality Director in the Department of Pediatrics as the Chair; 2) Chair of the Department of Pediatrics. 3) Chief Resident of the Pediatric Residency Training Program. 4) Representatives from the Medical Records. 5) Quality Management Team. 6) Health Information Technology Department and 7) Medical and Clinical Affairs. The idea for this project was initially discussed at the Pedi-atrics Departmental staff meeting in October 2012 and subsequently presented at the Med-ical Quality Management Committee and Medical Advisory Committee meetings in November 2012. With the agreement of all team members and approval of the process (Appendix I), the Discharge Process was officially launched in December 2012. Results: From the first quarter of 2011 (1131 delinquent medical records) to the first quarter of 2014 (68 delinquent medical records), a significant drop in the number of delinquent re-cords was documented. In addition, compliance with JCIA standards for documentation was measured by an audit of 20 randomly selected patient charts by the hospital quality manage-ment department. This audit demonstrated improvement from a compliance rate of 70%-79% between the first quarters of 2013 and 2014, respectively, and up to 86% in the second quarter of 2014. Consequently, the Department of Pediatrics ranked first among all hospital departments in the quality of their discharge summaries. Conclusions: Implementing a systematic framework to reinforce completion of patients’ discharge summaries leads to a better quality of documentation and minimizes unnecessary delay. Comprehensive and precise clinical documentation improves the quality of patient care and provides clear health information that is critical for ideal management of the health care system.