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Physicians use checklists for quality DP
Tool helps hospitals meet national quality measures
Mistakes happen even to the best clinicians. This is why hospitals increasingly are relying on checklists and other tools to assist clinicians in the discharge process.
One such tool, called a clinical decision support system, is an electronic checklist that enables hospital clinicians to meet all safety and quality goals every time they make a patient discharge.
The tool can assist hospitals with meeting quality measures used by the Hospital Quality Alliance (HQA) and Hospital Quality Incentive Demonstration (HQID) project.
A study comparing clinician compliance with heart disease treatment quality measures before and after use of an electronic checklist found significant improvement from the pre-intervention period to the post-intervention period. Clinicians' compliance with delivery of discharge instructions increased from 37.2% to 93% for acute myocardial infarction.1
Overall compliance with the cardiac discharge measures improved with the use of the clinical decision support system from 76.8% in the pre-intervention period to 96.8% in the post-intervention period.1
"It's not like a doctor ever wants to do the wrong thing, but you need another safety mechanism to assure 100% quality," says Jeff Riggio, MD, MS, physician advisor for information systems in the department of medicine, division of hospital medicine at Thomas Jefferson University Hospital in Philadelphia.
"We've realized the need to have systems in place, and having this as a computer-aided system has been helpful," Riggio says.
The hospital instituted the checklist for discharge planning involving cardiac patients with the help of a staff focus group and physician leaders, he says.
The movement toward using checklists partly is drawn from the airline industry, which instituted such processes to improve safety, he notes.
"The airline industry has translated many of its initiatives to improve quality and safety, and now we're taking advantage of their experiences," Riggio adds. "We're taking up their recommendations and adapting them for health care use."
Hospitals already have access to best practice guidelines. For instance, the Centers for Medicare & Medicaid Services (CMS) and the Hospital Quality Alliance have national quality initiatives. And various cardiac societies also have national guidelines involving cardiac care.
"So, we know what appropriate care is for our patients," Riggio says. "Unfortunately, to err is human, and people forget things; so we need a computerized system to help us achieve better compliance."
Electronic checklists can be useful tools for all clinical staff involved in the discharge process, including medical students, nurse practitioners, and attending physicians.
They works by having a section called the national quality measures section pop up on screen whenever a clinician keys in a specific diagnosis relevant to these measures.
"Once the appropriate diagnosis has been selected, there is a required checklist that needs to be performed before you can complete your documentation for the patient," Riggio explains. "You're forced to say whether or not you've prescribed an ACE inhibitor or given the patient appropriate discharge instructions."
The electronic system requires clinicians to answer a few questions before the discharge instructions are finalized.
"It takes an extra two minutes, if that long," Riggio says. "It's a mandated checklist. And for heart failure patients, there are two questions; and for acute myocardial infarction patients, there are four questions."
For a specific diagnosis, the electronic system will list patient instructions. These include having patients weigh themselves daily, follow their prescribed diet, know their activity recommendations, and understand their medication instructions.
"The program will require you to put in a follow-up post, and the program will have specific instructions for heart failure patients, talking about what to do if symptoms get worse and how to monitor weight," Riggio says. "This is automatically included in what's printed out for the patient."
Physicians can use their desktop computers to create the discharge instructions, which are all Web-based and available on the hospital's intranet, he adds.
"We're looking at putting computers in every room, but that's in the future," Riggio says.
One of the big mistakes that an electronic checklist can prevent involves whether or not physicians have reminded patients to take aspirin or prescribed an ACE inhibitor, he notes.
"For heart failure patients, the electronic prompt will remind them that the patient needs to be on an ACE inhibitor," Riggio says. "It reminds the discharging physician, because sometimes the discharging physician is not the physician who took care of the patient the entire time."
These continual hospital hand-offs are windows in which mistakes can occur, so the checklist is helpful in making sure the necessary communication occurs.
"It helps to double-check on prescriptions," Riggio says. "The physician might say that when the kidney function is better, we'll start an ACE inhibitor, and this will remind them to prescribe the drug."
The checklist also provides transparency in hospital care, and it's printed out and given to patients, who can see the quality measures for themselves. The total discharge instructions might be five pages with headers and page breaks; they're self-explanatory, listing medications and instructions about when to call a doctor. There are icons highlighting the various sections.
"Patients will be aware of quality standards for their disease process," Riggio says. "Patients often are never involved or see the end result; but we actually give them a copy of it, because this is one of the few documents we give patients routinely."
Some physicians and hospitals might debate the wisdom of sharing this information with patients, but from Riggio's perspective, it is the right move: "We felt this was the future [of medicine], to empower patients and have them understand these decisions we're making."
Typically, the physician will review the instructions with patients, although nurses might also be involved, Riggio says.
The other benefit to sharing the information is that the patient can take it to his or her community physician, who now will know why particular drugs were prescribed or not prescribed, he adds.
"Copies of these discharge instructions also could be sent to outside referring clinicians," he says.
The electronic checklist could be used by various health care systems as a means to improve clinical decision support at discharge.
"We've been working on rolling this out at an affiliate hospital in South Philly," Riggio says. "It has translatability to many different systems and hospitals."
[For more information, contact:
Jeff Riggio, MD, MS, Physician Advisor for Information Systems, Department of Medicine, Division of Hospital Medicine, Thomas Jefferson University Hospital, 833 Chestnut St., Suite 701, Philadelphia, PA 19107. E-mail: firstname.lastname@example.org.]