9 steps used in quality improvement

Committee follows process to find solution

To uncover the root cause of problems, determine a way to do something better, or meet a new Joint Commission on Accreditation of Healthcare Organizations requirement, staff at Methodist Hospitals of Memphis (TN) use a nine-step continuous quality improvement process.

"Once we identify a need, we use the formal process to take an intense look at the problem or issue," says Denise Thornton, RN, MSN, CDE, patient education coordinator. The steps help a team collect the data needed to determine a solution and create an action plan.

For example, when staff in the nursing department reviewed documentation of patient education as part of their continuous quality improve- ment efforts, they determined that each discipline documented in a different place, and the educational assessment was not interdisciplinary.

To remedy the situation, they assembled an interdisciplinary team that represented all clinical areas involved in teaching, such as nursing, dietary, and physical therapy. Here is a list of the steps they used to find a solution:

1. List and prioritize improvement opportunities. Chart audits had revealed a lack of documentation of discharge planning teaching, so the team decided that improving documentation was a priority. The team also listed combining the three forms currently being used into one interdisciplinary form as a second opportunity for improvement.

2. Define the improvement objectives. The measurable objective set by the team was that discharge planning and interdisciplinary patient education would be documented in the patient record 91% to 100% of the time. "We selected these numbers because 91% to 100% is the highest expectation of the Joint Commission," Thornton explains.

3. Define the requirements. The team defined four requirements:

— Meet the patient’s educational needs.

— Meet and exceed the current regulatory agency requirements.

— Promote interdisciplinary communication.

— Create a centralized space on the form for documentation of education to enhance continuity of care.

4. Collect and organize data. A survey was used to collect data. The team surveyed all disciplines that were potential users of the form, including physicians, to find out their documentation needs. Each discipline on the team took questionnaires to his or her department to distribute and return to the committee when completed.

5. Select the root cause. The team determined that the root cause of the problem was fragmentation of documentation for patient education. There were several places on the chart where all staff were expected to document patient education. Also, each discipline had its own special place for documentation, and there were too many forms for documenting patient education.

6. Generate potential solutions. The team brainstormed various ideas for improving patient education. When determining which solutions to implement, they looked at cost savings and gains, chance of success, and how much of the root cause the solution would remove. Possible solutions included:

— printing the form on brightly colored paper to attract attention;

— changing the name of the form;

— scheduling inservices on documentation;

— creating a chart divider to separate admission data, discharge planning data, and the interdisciplinary teaching record from the medical record;

— combining all three forms into one.

7. Select the best solution. The process helped the team members determine that the best solution was to combine forms. They created an interdisciplinary documentation form that combined assessment of readiness to learn and documentation of patient education. Small improve- ments included changing the name so "teaching record" was part of the title, creating a chart divider, and providing inservices after the form was implemented.

8. Implement the solution and evaluate the result. Each discipline represented on the team took the form back to his or her department for implementation. The departments wrote their own guidelines for use of the form and conducted their own inservices to educate staff. Allowing each department to implement the form rather than conducting hospitalwide inservices works best, because each has requirements unique to its discipline, explains Thornton.

Chart audits were used to evaluate the results. The nursing department checked the form to make sure that staff were assessing barriers to learning. They also checked to see if cultural and religious practices were assessed and taken into account when planning the patient’s care and teaching. Each department was asked to audit charts to make sure that documentation was being done correctly.

9. Continue to track. Departments audit charts for documentation of patient education quarterly. The results are given to the Patient Assessment Committee. This committee formed the team to find a solution for the documentation problem. "If the audits don’t reflect good documentation, we ask the department to submit a plan of action," Thornton says.