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Aligning complex processes and electronic health record templates: a quality improvement intervention on inpatient interdisciplinary rounds.

Mosher HJ, Lose DT, Leslie R, Pennathur P, Kaboli PJ - BMC Health Serv Res (2015)

Bottom Line: Unstructured evaluation indicated that documentation times were reduced, and IDR documentation became more timely and useful.IDR notes designed to support the problem-solving processes of an interdisciplinary group improved the timeliness and perceived value of IDR documentation and met regulatory standards.Aligning complex processes and educational and documentation needs during IDR may create an efficient opportunity for sustainable interdisciplinary work and learning in an academic setting.

View Article: PubMed Central - PubMed

Affiliation: Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System and VA Quality Scholars Fellowship Program, Iowa City, IA, USA. Hilary.mosher@va.gov.

ABSTRACT

Background: Interdisciplinary rounds (IDR) with documentation have become a standard of care, but the process has been incompletely described in academic general medical settings. Checklists are promoted, yet standardized formats may not reflect the variability and work flow of rounds or support the cognitive development of medical trainees. We describe IDR processes in an academic general medicine inpatient setting and present a rapid cycle quality improvement (QI) project that improved IDR documentation rates in the electronic health record.

Methods: The project team observed existing daily IDR rounds on two medical inpatient units at the Iowa City VA Medical Center, with three resident teams and maximum census of 42 patients. The major intervention was a redesigned note template, with accompanying resident educational materials. The primary outcome was note completion rates by charge nurses; IDR team member satisfaction and participation, discussion time and balancing metrics (i.e., excess bed days of care, length of stay, and 30-day readmissions) were also assessed.

Results: An electronic template and accompanying educational materials designed to parallel the heuristic problem-solving activities of the IDR team led to improvements in IDR note completion rates from 27 to 69 %. Team member satisfaction was high and participation was stable. Discussion time per patient increased modestly, but varied widely between resident teams and by patient. Balancing metrics were unchanged. Unstructured evaluation indicated that documentation times were reduced, and IDR documentation became more timely and useful.

Conclusions: IDR notes designed to support the problem-solving processes of an interdisciplinary group improved the timeliness and perceived value of IDR documentation and met regulatory standards. Aligning complex processes and educational and documentation needs during IDR may create an efficient opportunity for sustainable interdisciplinary work and learning in an academic setting.

No MeSH data available.


Interdisciplinary Rounds Project Design and Timeline
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Fig1: Interdisciplinary Rounds Project Design and Timeline

Mentions: The project timeline included three PDSA cycles including structured observations of the IDR process (Fig. 1). The first PDSA cycle incorporated a new white board system, conceptualized by the physician leaders as a way to visually represent a shared mental model of moving patients from admission to discharge. The new boards were installed with the intent that the team would integrate them into the daily workflow. The second PDSA cycle involved development and refinement of resident education materials, including handouts and pocket cards outlining the resident role during IDR that followed the content of the EHR note template (Additional file 2). The education materials were based on observations of residents considered by the interdisciplinary care team to be highly effective, and thus were descriptive rather than prescriptive. The third PDSA cycle involved redesign of the IDR note template. This original template was a long, detailed, check-list that included items unrelated to topics discussed in IDR. The length, detail, and content precluded real-time completion of the note during IDR rounds. Based on structured observations of IDR as well as unstructured interviews with the IDR team, the QI team redesigned the template to include common issues and reflect the order of typical discussions, especially those led by residents felt by the IDR team to be most effective. The template was iteratively trialed and modified based on feedback from the charge nurses completing the note (Additional file 3). Resident education materials were designed to parallel the template. As part of continuous QI, resident education materials were expanded into a short video podcast to be shown at the beginning of each month-long rotation [18].Fig. 1


Aligning complex processes and electronic health record templates: a quality improvement intervention on inpatient interdisciplinary rounds.

Mosher HJ, Lose DT, Leslie R, Pennathur P, Kaboli PJ - BMC Health Serv Res (2015)

Interdisciplinary Rounds Project Design and Timeline
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4499441&req=5

Fig1: Interdisciplinary Rounds Project Design and Timeline
Mentions: The project timeline included three PDSA cycles including structured observations of the IDR process (Fig. 1). The first PDSA cycle incorporated a new white board system, conceptualized by the physician leaders as a way to visually represent a shared mental model of moving patients from admission to discharge. The new boards were installed with the intent that the team would integrate them into the daily workflow. The second PDSA cycle involved development and refinement of resident education materials, including handouts and pocket cards outlining the resident role during IDR that followed the content of the EHR note template (Additional file 2). The education materials were based on observations of residents considered by the interdisciplinary care team to be highly effective, and thus were descriptive rather than prescriptive. The third PDSA cycle involved redesign of the IDR note template. This original template was a long, detailed, check-list that included items unrelated to topics discussed in IDR. The length, detail, and content precluded real-time completion of the note during IDR rounds. Based on structured observations of IDR as well as unstructured interviews with the IDR team, the QI team redesigned the template to include common issues and reflect the order of typical discussions, especially those led by residents felt by the IDR team to be most effective. The template was iteratively trialed and modified based on feedback from the charge nurses completing the note (Additional file 3). Resident education materials were designed to parallel the template. As part of continuous QI, resident education materials were expanded into a short video podcast to be shown at the beginning of each month-long rotation [18].Fig. 1

Bottom Line: Unstructured evaluation indicated that documentation times were reduced, and IDR documentation became more timely and useful.IDR notes designed to support the problem-solving processes of an interdisciplinary group improved the timeliness and perceived value of IDR documentation and met regulatory standards.Aligning complex processes and educational and documentation needs during IDR may create an efficient opportunity for sustainable interdisciplinary work and learning in an academic setting.

View Article: PubMed Central - PubMed

Affiliation: Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System and VA Quality Scholars Fellowship Program, Iowa City, IA, USA. Hilary.mosher@va.gov.

ABSTRACT

Background: Interdisciplinary rounds (IDR) with documentation have become a standard of care, but the process has been incompletely described in academic general medical settings. Checklists are promoted, yet standardized formats may not reflect the variability and work flow of rounds or support the cognitive development of medical trainees. We describe IDR processes in an academic general medicine inpatient setting and present a rapid cycle quality improvement (QI) project that improved IDR documentation rates in the electronic health record.

Methods: The project team observed existing daily IDR rounds on two medical inpatient units at the Iowa City VA Medical Center, with three resident teams and maximum census of 42 patients. The major intervention was a redesigned note template, with accompanying resident educational materials. The primary outcome was note completion rates by charge nurses; IDR team member satisfaction and participation, discussion time and balancing metrics (i.e., excess bed days of care, length of stay, and 30-day readmissions) were also assessed.

Results: An electronic template and accompanying educational materials designed to parallel the heuristic problem-solving activities of the IDR team led to improvements in IDR note completion rates from 27 to 69 %. Team member satisfaction was high and participation was stable. Discussion time per patient increased modestly, but varied widely between resident teams and by patient. Balancing metrics were unchanged. Unstructured evaluation indicated that documentation times were reduced, and IDR documentation became more timely and useful.

Conclusions: IDR notes designed to support the problem-solving processes of an interdisciplinary group improved the timeliness and perceived value of IDR documentation and met regulatory standards. Aligning complex processes and educational and documentation needs during IDR may create an efficient opportunity for sustainable interdisciplinary work and learning in an academic setting.

No MeSH data available.