Utilizing Data in a Perioperative Electronic Health Record to Drive Quality Improvement

Purpose:
Study of specific fields within Perioperative documentation allows us to analyze compliance with National Patient Safety Goals and Surgical Care Improvement Project protocol. Review of data assists in performance improvement thus improving care of our patients.

Significance:
An estimated 2.5 to 3.5 million patients per year experience unintended harm related to surgical interventions. Standardization and compliance of documentation in key data entry fields improves hand off communication, demonstrates compliance with standards and provides evidence of care rendered.

Strategy and Implementation:
Key data field elements pertaining to SCIP protocol and NPSG were built into the Perioperative electronic documentation with our last upgrade. Specific fields were audited for compliance by staff RN's in the Operating Room. Some of the fields are set up as “hard stops” while others do not prevent the chart from being closed even if not completed. Measurement and analysis of compliance were audited and assessed. Results were communicated by use of reports and graphs. This process is ongoing as well as need to increase or decrease the “hard stop” elements.

Evaluation:
Monthly compliance rates are graphed and communicated to the health care team. The goal is one hundred percent compliance of documentation. Graphs were used to communicate high level information to administration as well as ground roots communication to the staff and physicians working in the areas.

Implications for Practice:
Compliance of electronic documentation improves patient care, streamlines processes and also provides data necessary to meet SCIP protocols and The Joint Commission NPSG. Standardizing processes allows for consistency of information and workflow.