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Improving documentation step by step
By Stephanie Minix, RN
Clarissa Mercer, RN
Patient Education Coordinators
The Medical Center of Central Georgia
The Patient and Family Education department at the Medical Center of Central Georgia in Macon has been involved in a process improvement project using an internal process called the 7-Step Operation Improvement Model. The purpose of this project is to improve interdisciplinary documentation of patient and family education in the medical record. The steps of this Operation Improvement project include:
1. Identify the problem.
Closed medical record data from November 1997 to August 1998 were used to evaluate continuumwide compliance with documentation of activities that meet Joint Commission standards for Patient and Family Education. The findings revealed there was inadequate evidence in the patient record of the educational process being collaborative and interdisciplinary as appropriate to the plan of care. The threshold of compliance for this Joint Commission standard (PF.4.2) is 100%, and compliance at The Medical Center was in the 80th percentile.
Prior to our Joint Commission survey in 1996, a documentation process and tool were being used for patient education. The tool was kept in a standardized location in the medical record so all disciplines could clearly identify and access it. Based on data collected, this had ceased to be effective.
An interdisciplinary Operation Improvement (OI) team was formed with representatives from inpatient, outpatient, and ambulatory areas. Several of the OI members are also members of the organization’s Patient Education Advisory Committee. The advisory committee is involved in addressing patient and family education issues and needs throughout the organization. The committees’ functions include:
• development of policies, procedures, and guidelines related to patient education;
• standardization of patient education materials;
• monitoring Joint Commission standards and compliance;
• dissemination of patient education information to clinical areas;
• identification of training needs for staff related to patient education;
• identification of continuumwide patient education needs.
Disciplines represented on the OI team included pharmacy, nursing, case management, outcomes management, respiratory therapy, health educators, medicine, information systems, and dietary.
2. Describe current process.
The current process for documentation of patient education was identified through flowcharts describing this process for the following clinical areas: Schoolhouse Health, Radiology, Just For Today, Respiratory, Case Management, Nursing, Nutrition, Pharmacy, Med Centers, Children’s Health Center, Physicians, Family Health Center, Rehabilitation Services, Financial Services, Surgical Associates, Emergency Center, and Diabetes Treatment Center. The flowcharts revealed that each of the clinical areas mentioned had a different process for documentation of patient education.
3. Identify root causes.
Reasons identified for lack of interdisciplinary documentation included: time constraints, chart and teaching form unavailable, lack of leadership commitment and follow-through, employee apathy, inadequate education and training, and multiple documentation requirements. Root causes were identified through team participation in an affinity exercise diagram, where a large number of ideas and issues were grouped into major cause categories. Then a fishbone diagram was developed to show relational causes to a lack of interdisciplinary documentation.
Survey validated OI team’s conclusions
A staff survey was conducted to determine whether root causes identified by the interdisciplinary team were the actual reasons for the lack in documentation. The survey included the major root causes identified for lack of interdisciplinary documentation and measured the frequency with which these causes occurred over four days. In order to be representative of fluctuations in staffing and census, the survey was conducted on both weekday and weekends. This survey validated the conclusions of the OI team.
4. Develop solution and action plan.
The team evaluated major root causes based on the Pareto chart developing and identifying those within their control. A Pareto chart is used to focus on key problems by showing their relative frequency or size in a descending bar graph. Key problems were:
— other work was a priority;
— duplication of documentation;
— the medical chart was unavailable;
— the form was not available.
Based on the data obtained through the assessment and evaluation process, three solution/action plans were developed to improve interdisciplinary documentation.
• Action Plan No. 1: The Multidisciplinary Plan of Care and Teaching Record were integrated to increase interdisciplinary/collaborative documentation of patient and family education by decreasing the "documentation" workload. This step also facilitated fuller integration of patient education into the plan of care.
• Action Plan No. 2: Internal monitoring mechanisms that would increase the sample size of records reviewed to identify compliance issues were created. This involved identifying existing departmental internal monitoring mechanisms that would supplement the current closed medical record review process. The decision was made to expand the number of closed medical record reviews rather than incorporating another process.
• Action Plan No. 3: Staff meetings were changed to include patient and family education as a standard agenda item. The purpose is to review unit-specific data relative to documentation compliance, areas for improvement, and other patient education issues. The department-based educator or some other designated staff member presents patient education on each clinical department staff meeting agenda.
5. Implement solution or process change.
Following Action Plan No. 1, the Multidis ci plinary Plan of Care and the Teaching Record were combined to decrease the documentation workload and implemented in September 1998. (See example of this document, inserted in this issue.) Approximately 910 of 1,200 employees documenting patient teaching in the medical record attended the mandatory blitz. The employees unable to attend were taught on their individual units by the department-based educator and the patient education coordinators.
The patient education coordinators developed a new process of reporting data pulled from the closed medical record. A comparative report of the data was sent to directors, assistant directors, and department-based educators of all inpatient and ambulatory sites throughout the institution. As areas for improvement were identified, the patient education coordinators would meet with these individuals to develop action plans for improvement.
According to Action Plan No. 2, the number of closed medical records reviewed was increased from 4% to 5% of all discharges for each unit. This increased identification of compliance issues.
In accordance with Action Plan No. 3, the patient education coordinators attended staff meetings to emphasize proper use of the form and to address other patient education issues. Patient education was added to all clinical department staff meetings. The specific item on the agenda is determined by current unit issues related to patient education and is presented by the department-based educators or other designated staff member.
6. Evaluate result of change.
The closed medical record data from September 1998 to March 1999 showed a significant improvement in compliance with the Joint Commission standard to make the educational process collaborative and interdisciplinary (PF.4.2). Hospitalwide compliance reached 99% in March 1999. The average for this standard over the past year is 95.6% and ranged from 99% to 88%.
7. Apply experience.
The patient education coordinators periodically conduct unit spot checks of staff documentation to identify areas for improvement and answer questions regarding the form. When they met with leaders of various units, suggestions were made to improve compliance with the Joint Commission standards on their units. During one of the meetings, the suggestion was made to evaluate the effectiveness of having preprinted information on the form. This would assist staff in documenting pertinent issues related to the plan of care and likewise meet those Joint Commission standards in which we were consistently below the compliance threshold.
The suggestion was implemented, and pre-printed information has increased compliance. The three standards selected to be preprinted on the documentation tool were medical equipment (PF 1.4), food and drug interaction (PF 1.5), and medications (PF 1.3). Increased compliance was noted for documentation of education on medical equipment and medications. We continually evaluate how we can achieve compliance with the Joint Commission PF standards. As compliance issues are identified, the patient education coordinators work with specific units to correct deficiencies. To further enhance documentation compliance throughout the organization, they share unit success stories with other units needing assistance.
For more information on improving documentation of patient education, contact:
• Stephanie Minix, RN, Patient Education Coordinator, The Medical Center of Central Georgia, P.O. Box 6000-Hospital Box 125, Macon, GA 31208. Telephone: (912) 633-7719. E-mail: email@example.com.
• Clarissa Mercer, RN, Patient Education Coordinator, The Medical Center of Central Georgia, P.O. Box 6000-Hospital Box 125, Macon, Georgia 31208. Telephone: (912) 633-1123. E-mail: firstname.lastname@example.org.