Quality Improvement Through Improved Documentation
Kenneth Lobe, BSN, RN
- Sigma Affiliation
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Session J presented Saturday, September 16, 2017
Purpose: To optimize practice standards in accordance to regulatory requirements the organizational policy for Emergency Department (ED) documentation was created. The Quality Improvement (QI) project focused on application of the policy, augmenting current nursing documentation to enhance communication of the patient’s ED trajectory.
Design: The project focused on professional development ensuring documentation reflects the patient’s journey promoting quality care leading to best patient outcomes.
Setting: The Swedish/Ballard Campus is a community hospital in Seattle. The community has transformed, business relocation to the Ballard community maintaining close relationship to downtown Seattle has created a community with greater numbers of young families. Research shows that documentation in the ED has unique challenges due to the intensity of service and rapid patient turnover. The fast-paced environment requires focused strategies and structures to meet regulatory requirements aimed at optimizing patient outcomes. A review of organizational standards led to creation in ED documentation policy.
Participants/Subjects: All staff was encouraged to participate. Through participation staff had opportunity to review personal documentation practices and compare to the policy. The project provided opportunity for professional development while ensuring documentation reflected the patient’s journey.
Methods: Nursing documentation provides key information describing a patient’s journey detailing patient concerns, interactions, interventions, and response. Implementation of a QI initiative was targeted on disseminating new documentation standards in a meaningful way engaging frontline nurses to be accountable for their documentation practice. Formal and informal presentations were conducted disseminating the new documentation policy. Next staff completed 3 anonymous random audits of their documentation using an audit tool outlining the 16 data points of the new policy. Baseline audits revealed >90% compliance in many of the 16 data points. The project lead and ED manager used the initial audit to establish a baseline. Focus was place on 4 data points with the lowest percentages, social/behavioral screen, hourly VS, ongoing assessment and removal of peripheral intravenous catheter (PIV), to focus on improvement. Ongoing audits and assessments were conducted to evaluate the efficacy of the change, presenting results at mandatory staff meetings and posting in the ED.
Results/Outcomes: The initial audit (October 2015) included 41 chart audits revealing 4 data points for focused improvement: social/behavioral screening (68%), hourly VS (69%), ongoing assessment (74%), and removal of PIV (63%). Follow up and education allowed time for staff to enhance personal practice. Additional audits were conducted (December 2015/July 2016/December 2016) to assess ongoing improvement/sustainability (N=49, N=81, N=81 respectively) revealed the following results: social/behavioral screening (75-86-78%), hourly VS (85-87-96%), ongoing assessment (84-81-94%), and removal of PIV (70-62-91%) uncovering a continued improvement and sustainability.
Implications: Nursing documentation standards are a challenge. The results of this project show that we can make improvements and ultimately impact patient outcomes through better telling of their story. Setting the standard, educating staff and having staff review documentation improves practice. The data further showed sustained and continued improvement. Future audit and monitoring will evaluate the extent of the engagement and commitment to nursing documentation and the integration of the standards into the department’s culture.
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