Improvement In Quality Of Documentation Research Articles

831 Improving Documentation of Post-Operative Day 1 Checks After a Hip Hemiarthroplasty or Total Hip Replacement

Abstract Background Post-operative day 1 checks (X-ray, bloods, dressing check and neurovascular status) are essential after hemi-arthroplasty (hemi) or total hip replacements (THR) to look for peri-prosthetic fracture, dislocation, anaemia, acute kidney injury, wound site bleeding and neurovascular impairment. Senior clinicians in the T&O department at the trust have raised concerns regarding documentation of post-operative day 1 checks in hemi/THR patients. Thus, offering no certainty to doctors reviewing patients at a later date that day 1 checks were carried out. Ultimately, raising the issue of patient safety. Aim The aim of this audit was to improve documentation of post-operative Day 1 checks in hemi/THR patients. Method Medical notes of those who underwent either a hemi/THR were reviewed. They were appraised on day 1 post-operative documentation of review of xray, acknowledgment of bloods results, dressing and NV status checks. Two PDSA cycles were carried out between September – November 2022. Interventions included: a) raising awareness on the junior doctor WhatsApp group; b) educating junior doctors via teaching sessions. Results 40 medical notes were reviewed during each cycle. Results showed a clear improvement in quality of documentation. Pre-intervention (cycle 1): X-ray (37.5%), bloods (25%), dressing (52.5%), NV status (47.5%). Post-intervention (cycle 2): X-ray (71.5%), bloods (75%), dressing (72.5%), NV status (77.5%). Conclusions The relatively simple interventions have been found to have an improvement in documentation of post-operative day 1 checks in hemi/THR patients. Further recommendations include: raising awareness during induction and posters on the ward to prompt junior doctors to complete these checks.

Pitfalls in Perioperative Documentation, Compliance with the EMR

<h3>Background Information</h3> In 2018, Perianesthesia nurses at Delnor Hospital embarked on a documentation quality improvement initiative. A team of nurses collaborated to promote consistency in standardized documentation within The American Society of Perianesthesia Nurses (ASPAN) guidelines by enhancing electronic documentation. A workgroup was developed with representation from Pre-op, Phase I, Phase II, Professional Development, and Perioperative Leadership with both surgical areas within Delnor. The team established documentation guidelines based ASPAN standards. Education was developed along with an audit tool to measure compliance. Baseline data from the start of the project in 2018 identified documentation compliance was less than 62% for all areas. A goal was established to improve compliance to 85%. After three months of audits, all three areas achieved the goal and exhibited significant improvement. With continued audits and peer coaching provided by the documentation committee compliance was achieved. However, after the pandemic hit sustainment of the goal decreased in compliance. <h3>Objectives of Project</h3> The committee focused on reeducation of the team and audits to reestablish the expectation, hold staff accountable and get back to the targeted goal. <h3>Process of Implementation</h3> A pre-learning audit was completed to determine baseline data and where reeducation was needed. The education was disseminated to the staff in the three phases of care. The documentation guidelines and education were added to the orientation binder for new staff. Twenty audits were completed monthly per area for three consecutive months. The re-introduction of the project was received positively and the staff felt empowered with knowledge, increased confidence on appropriate assessment/documentation, and improved communication through the Perioperative setting. It was identified that staff who were non-compliant, were the ones who were resistant to the initial project and fell back to old habits. <h3>Statement of Successful Practice</h3> The committee realized that accomplishing the goal is important but identified that sustainment is the most crucial aspect of the project. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> The documentation group will continue to monitor documentation, provide additional education for compliance and focus next on case-specific assessment/documentation.

Eliminating Sex-Based Disparities in Statin Prescriptions Following Open Revascularization for CLTI Through Universal Documentation

Women have been shown to have worse clinical outcomes compared with men following treatment for peripheral arterial disease. Although the reasons for this remain unclear, disparities in evidence-based medical management have been suggested as one potential cause. As a part of the Northern California Vascular Quality Initiative (VQI) regional collaborative, a universal discharge documentation quality improvement initiative was implemented to address discharge medication prescriptions. We hypothesized that implementation of universal discharge documentation would decrease disparities in statin prescription after open vascular procedures for chronic limb-threatening ischemia (CLTI). A single-center retrospective analysis was performed using electronic health record warehouse data extraction with medical record review auditing. Patients with CLTI who had undergone open lower extremity bypass or femoral endarterectomy from 2012 to 2020 were included. The primary end point was a statin prescription within 30 days after the procedure. A time series analysis was performed comparing the primary end point before and after implementation of universal discharge documentation in May 2018. Sex was defined as the birth sex as reported in the medical record. Logistic regression was used to estimate the associated change in statin prescription by sex. A total of 357 cases were included, with 144 women (40%) and 213 men (60%). Before implementation, statins had been prescribed to 87% of the men and 69% of the women (P < .01). After implementation of the universal discharge documentation, there was no difference in statin prescription (88% for men vs 95% for women; P = .19). On logistic regression, men had 3.0 times the odds of being prescribed a statin before implementation (odds ratio, 3.0; 95% confidence interval, 1.6-5.6; P < .01). Following implementation of the initiative, the improvement in the odds of women receiving statins was eight times that of men (odds ratio, 8.2; 95% confidence interval, 1.5-46.1; P = .02). Implementation of universal discharge documentation eliminated sex-based disparities in discharge statin prescription following open revascularization for CLTI. These findings suggest that regional VQI initiatives aimed at improving discharge documentation might also play an important role in addressing disparities in vascular care. Future study is necessary to better understand how universal discharge documentation might affect sex-related and other disparities across VQI modules at the regional level.

Quantifying the health needs of migrants in vulnerable circumstances registered with a nurse-led primary care service.

As of the end of 2019, at least 79.5 million people worldwide have been forced to flee their homes. Those seeking asylum face adversity before, during and after arrival in the UK, resulting in complex health and social needs. The study setting was a nurse-led asylum seeker service in a dispersal city, commissioned to provide an initial health assessment, immunisations and support to register with a general practitioner. The aim was to quantify the health needs of migrants in vulnerable circumstances registered with a nurse-led primary care service by clinical audit. In June 2018, 80 electronic records were reviewed by seven auditors to analyse documentation of demographics, asylum status, service use, barriers to care, physical and mental health. Where data were available, 86% migrated due to persecution or trafficking, 59% had a chronic physical illness, 51% had a mental health condition and 49% experienced barriers to accessing a mainstream general practitioner. Although a small sample, this survey demonstrated high physical and mental health needs that are often unmet in mainstream services. There was a high level of unknown need, for example of torture rates. These findings informed quality improvement in documentation and health assessments, and further research.

A Structured Maternity Case Record to Improve Quality of Documentation in a Tertiary Care Hospital, Delhi

Introduction: India contributes to about 18% of global maternal deaths and 22.6% of still births. Efforts to improve the quality of care are challenged by the lack of reliable documentation of data. Hence, a concise, structured maternity case sheet (PrasavRecord) was designed with the aim to bring about an improvement in documentation of treatment and events related to woman in labour from the time of admission till her discharge from the hospital. Aim: To study the improvement in quality of documentation from the time of admission till discharge of a woman in labour with the help of structured format i.e., PrasavRecord. Materials and Methods: The study was conducted in February 2017. A quasi experimental study design was used, and the completeness of data recorded by the resident doctors in the existing hospital case sheet (control group) with those recorded in PrasavRecord (intervention group) were assessed in a total of 65 deliveries in each arm. Details of the patient from admission to the labour room followed by the entire sequence of events during labour as well as hospital stay in postpartum period were recorded over 130 parameters under different sections in PrasavRecord. Statistical analysis was done by using SPSS version 21.0. Results: Completeness of the documentation in terms of history, investigations and findings at examination including those at labour, nearly, 92% of the doctors rated PrasavRecord as “good and very good” for appearance, recommended its routine use, and 75% agreed that the format will be useful for conversion to electronic medical record. There was highly significant difference between the average percentage of completeness in PrasavRecord 75.8 {95% CI (74.2-77.4)} and hospital case sheets 42.2 {95% CI (40.9-43.6)} i.e., z=5.38 p-value &lt;0.001. Conclusion: PrasavRecord is a simple, acceptable and user-friendly data entry format which improves the quality of documentation of the processes and practices during childbirth. Larger trials are required to finetune it to facilitate its widespread use thereby, ensuring a uniform documentation process of labour and postpartum.

Evaluating documentation of social history in paediatric medical notes at a regional paediatric centre \u2013 a quality improvement initiative

BackgroundA child’s home and family environment plays a vital role in neuro-cognitive and emotional development. Assessment of a child’s home environment and social circumstances is an crucial part of holistic Paediatric assessment.AimsOur aim is to achieve full compliance with comprehensive documentation of biopsychosocial history, for all children medically admitted to the children’s inpatient unit in University Hospital Limerick.MethodsWe performed a retrospective chart review to audit documentation within our department. This was followed by teaching interventions and a survey on knowledge, attitudes and behaviour of paediatric non-consultant hospital doctors (NCHDs) towards the social history. We performed two subsequent re-audits to assess response to our interventions, and provided educational sessions to seek improvement in quality of care.ResultsResults showed a significant improvement in quality of documentation following interventions, demonstrated by a net increase of 53% in levels of documentation of some social history on first re-audit. Though this was not maintained at an optimum level throughout the course of the year with compliance reduced from 95% to 82.5% on second re-audit, there was nonetheless a sustained improvement from our baseline. Our qualitative survey suggested further initiatives and educational tools that may be helpful in supporting the ongoing optimisation of the quality of documentation of social history in our paediatric department.ConclusionWe hope this quality improvement initiative will ultimately lead to sustained improvements in the quality of patient-centred care, and early identification and intervention for children at risk in our community.

Using a multisite and multi–health system pharmacy resident program model for care documentation quality improvement

ObjectivesTo implement and evaluate a pharmacy resident documentation peer review process. SettingThe University of Minnesota Postgraduate Year One Pharmacy Residency Program is a multisite program with 25 residents across 16 different health care organizations. Practice descriptionSites within the program provide comprehensive medication management (CMM) services to patients in ambulatory care settings, including participation in the full patient care process of assessment, care plan development, follow-up, and appropriate documentation. Practice innovationIn this innovative peer review process model, residents undergo a deidentified CMM documentation review process with residents from other practice sites, exposing them to different documentation templates and perspectives. EvaluationA workgroup of residency preceptors led by a research team developed a peer review process, which evolved through 3 phases over 2 years in response to resident, preceptor, and administration team feedback. Resident feedback was compiled and analyzed. ResultsForty-two residents responded to the survey (67% response rate); 71% found the review process to be helpful. Residents reported that the process improved their understanding of how to improve patient care documentation (74%), how to provide peer feedback (90%), and the importance of effective interprofessional communication in clinical decision making (81%). DiscussionThe core perceived benefit of the peer review process was exposure to how other health systems and practitioners document CMM. Some residents participate in a peer review process at their home institutions, which may explain some of the lack of perceived benefit. Generalizability of this study is limited by being within a single residency program with a relatively small number of participants. ConclusionPharmacy residents found a peer review process of documentation to be helpful during their residency education. The process exposed residents to different documentation practices at various health care systems, which led to ideas of how to improve documentation and provided a foundation for how to provide peer feedback in practice.

Quality improvement in documentation for patients with suspected facial fractures: use of a structured record keeping tool

ObjectivePatients with injuries to the midface frequently sustain ophthalmic injuries and fractures to the facial bones. Despite this, basic ophthalmic examination and assessment of important clinical signs are often missing...

Medical tourism opportunities and challenges: Illustration from US–India trade*

Medical tourism constitutes one form of international trade in services. There has been continuing interest in the size of this segment of trade, the direction of this trade (e.g., west to east, south to north), the growth prospects for this trade, and the ability of tourism to disrupt healthcare delivery in the west. Unfortunately, research on this segment of trade has lagged behind the speculation and hype. This article examines the size and growth of this trade, and finds the volume nowhere near the original estimates. The article then examines the ability of US–India medical tourism to deliver on ‘value’ (quality divided by cost), solve the ‘iron triangle’ of healthcare (improving access and quality while controlling cost), and ‘bend the trend’ in rising healthcare costs. To deliver on this value, India's healthcare system will need to develop significant capabilities in areas that document quality improvement along with lower cost. The article concludes with a discussion of two trends taking place in both countries that can potentially thwart the disruptive force of medical tourism.

Audit and feedback intervention: An examination of differences in chiropractic record-keeping compliance.

Objective : The objective of this study was to investigate the association of a clinical documentation quality improvement program using audit-feedback with clinical compliance to indicators of quality chart documentation. Methods : This was an analysis of differences between adherence to quality indicators of chiropractic record documentation and audit-feedback intervention (feedback report only vs. feedback report with one-on-one educational consultation) at different campuses. Comparisons among groups were analyzed using analysis of variance (ANOVA), Tukey or Dunnett post hoc tests, and Cohen's d effect size estimates. Results : There was a significant increase in the mean percentile compliance in 2 of 5 compliance areas and 1 of 11 compliance objectives. Campus B demonstrated significantly higher levels of compliance relative to campus A and/or campus C in 5 of 5 compliance areas and 7 of 11 compliance objectives. Across-campus comparisons indicated that the compliance area Review (Non-Medicare) Treatment Plan [F(2,18) = 17.537, p < .001] and compliance objective Treatment Plan Goals [F(2,26) = 5.653, p < .001] exhibited the highest practical importance for clinical compliance practice. Conclusions : Feedback of performance improved compliance to indicators of quality health record documentation, especially when baseline adherence is relatively low. Required educational consultations with clinicians combined with audit-feedback were no more effective at increasing compliance to indicators of quality health record documentation than audit-feedback alone.

Quality improvement in clinical documentation: does clinical governance work?

IntroductionThe quality of nursing documentation is still a challenge in the nursing profession and, thus, in the health care industry. One major quality improvement program is clinical governance, whose mission is to continuously improve the quality of patient care and overcome service quality problems. The aim of this study was to identify whether clinical governance improves the quality of nursing documentation.MethodsA quasi-experimental method was used to show nursing documentation quality improvement after a 2-year clinical governance implementation. Two hundred twenty random nursing documents were assessed structurally and by content using a valid and reliable researcher made checklist.ResultsThere were no differences between a nurse’s demographic data before and after 2 years (P>0.05) and the nursing documentation score did not improve after a 2-year clinical governance program.ConclusionAlthough some efforts were made to improve nursing documentation through clinical governance, these were not sufficient and more attempts are needed.

Documenting Quality Improvement and Patient Safety Efforts: The Quality Portfolio. A Statement from the Academic Hospitalist Taskforce

Physicians increasingly investigate, work, and teach to improve the quality of care and safety of care delivery. The Society of General Internal Medicine Academic Hospitalist Task Force sought to develop a practical tool, the quality portfolio, to systematically document quality and safety achievements. The quality portfolio was vetted with internal and external stakeholders including national leaders in academic medicine. The portfolio was refined for implementation to include an outlined framework, detailed instructions for use and an example to guide users. The portfolio has eight categories including: (1) a faculty narrative, (2) leadership and administrative activities, (3) project activities, (4) education and curricula, (5) research and scholarship, (6) honors, awards, and recognition, (7) training and certification, and (8) an appendix. The authors offer this comprehensive, yet practical tool as a method to document quality and safety activities. It is relevant for physicians across disciplines and institutions and may be useful as a standalone document or as an adjunct to traditional promotion documents. As the Next Accreditation System is implemented, academic medical centers will require faculty who can teach and implement the systems-based practice requirements. The quality portfolio is a method to document quality improvement and safety activities.

Quality Improvement in Documentation of Postoperative Care Nursing Using Computer-Based Medical Records

Postanesthesia nursing should be documented with high quality. The purpose of this retrospective case-based study on 49 patients was to analyze the quality of postoperative documentation in the two existing templates and, based on this audit, to suggest a new template for documentation. The audit on the template with quantitative data showed satisfactory documentation of postoperative care nursing in 67% (18% to 92%; mean [min-max]) of the scores. The template for documentation using qualitative descriptions was used by 63% of the nurses, but the keywords were used to a varying degree, that is, from 0% to 63% of records. The analysis also revealed noncompliance with clinical guidelines and multiple duplicate entries. Based on this audit, a new template was constructed, with 10 physiological parameters and drop-down lists with keywords within each parameter. In this way, implicit knowledge could be converted to explicit documentation. Furthermore, the quality of documentation was improved.

Use of a structured template to facilitate practice-based learning and improvement projects.

The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to meet and demonstrate outcomes across 6 competencies. Measuring residents' competency in practice-based learning and improvement (PBLI) is particularly challenging. We developed an educational tool to meet ACGME requirements for PBLI. The PBLI template helped programs document quality improvement (QI) projects and supported increased scholarly activity surrounding PBLI learning. We reviewed program requirements for 43 residency and fellowship programs and identified specific PBLI requirements for QI activities. We also examined ACGME Program Information Form responses on PBLI core competency questions surrounding QI projects for program sites visited in 2008-2009. Data were integrated by a multidisciplinary committee to develop a peer-protected PBLI template guiding programs through process, documentation, and evaluation of QI projects. All steps were reviewed and approved through our GME Committee structure. An electronic template, companion checklist, and evaluation form were developed using identified project characteristics to guide programs through the PBLI process and facilitate documentation and evaluation of the process. During a 24 month period, 27 programs have completed PBLI projects, and 15 have reviewed the template with their education committees, but have not initiated projects using the template. The development of the tool generated program leaders' support because the tool enhanced the ability to meet program-specific objectives. The peer-protected status of this document for confidentiality and from discovery has been beneficial for program usage. The document aggregates data on PBLI and QI initiatives, offers opportunities to increase scholarship in QI, and meets the ACGME goal of linking measures to outcomes important to meeting accreditation requirements at the program and institutional level.

72 Parental Satisfaction Concerning Their Child's Hospital Care: A Questionnaire Survey

Background: Nowadays, healthcare needs to be more evidence-based, patient-oriented and families' perspectives must be taken into account in the appraisal of health services. Aim: The aim of this study was to rate parental satisfaction concerning their child care during hospitalization and the factors that determine it. Methods: Parents of 206 children, randomly selected, hospitalized in two pediatric and two surgical units. Data collection was based on interviews using a 68 item questionnaire, the Swedish Pyramid Questionnaire. Stepwise multiple regression was used to explore the characteristics which may have affected the parents' answers. Results: Parents showed greater satisfaction with staff attitudes and medical treatment, whereas they were less satisfied with the information concerning routines and the staff work environment. They were pleased by the nursing care (N=180, 87.37%), nurses' concern (N=179, 86.89%) and from the respect to their needs (N=181, 87.86%) or their child's needs (N=186, 90.29%). Fathers gave statistically significant higher ratings for information about illness than mothers did (U=2416.000, p=0,035). Adequacy of care, adequate pain management, parents' involvement in care, trusting relationship and staff attitudes were the most important determinants of parental satisfaction. Conclusions: Parental satisfaction can be used as an indicator of the quality of care experienced by parents and patients. Interventions in pediatric care should include measurements of parental and child satisfaction, along with quality of care during treatment's outcomes assessment since hospitals are obliged by the state and private sector to document quality improvement measures.