4508 Final Quality Project Part 1: Quality Improvement and the EHR

Overview

This activity focuses on Quality Improvement using EHRs. The activity uses online resources as well as copies of actual medical records. For this assignment, you will perform an audit of the documentation of consents in the chart for accuracy and quality. Afterwards, you will make recommendations about the consent and audit process. This encompasses quality management, performance improvement and initiatives within a healthcare system.

Quality Improvement (QI): Systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups. (www.hrsa.gov) Continuous Quality Improvement (CQI): Is a quality management process that encourages all health care team members to continuously ask the questions, “How are we doing?” and “Can we do it better?” (Edwards, 2008). To address these questions, a practice needs structured clinical and administrative data. (www.healthit.gov) Rapid-Cycle Quality Improvement: A QI methodology that was developed out of the need to see improvement quicker. It reduces wasted activity and efforts for a quick turnaround on QI projects. PDSA/PDCA: Plan, Do, Study/Check, Act. A commonly used QI strategy that is a four step rapid-cycle quality improvement strategy.

• Plan: Identify an opportunity to improve and plan a change • Do: Carry out the plan on a sample number of patients. • Study/Check: Examine the results. Were your goals achieved? • Act: Use your results to make a definitive decision. Incorporate the changes into your

workflow.

SMART Goals:

• Specific (simple, sensible, significant). • Measurable (meaningful, motivating). • Achievable (agreed, attainable). • Relevant (reasonable, realistic and resourced, results-based). • Time bound (time-based, time limited, time/cost limited, timely, time-sensitive).

http://www.hrsa.gov/
http://www.healthit.gov/
Activity 1

Watch video: Implementing EHRs to Improve Healthcare Quality: https://youtu.be/okO8Z7ZPPuw

Watch video: The Path to Interoperability: https://youtu.be/PaWcU7rqqyA

Answer questions 1-3.

1. Most physicians feel as if EHRs do not save them time. What is your response to this? a. Were EHRs designed to “save time” in the healthcare documentation process? b. If not, what was the EHR designed to do? Be thorough in your response.

2. When implementing organization wide QI initiatives, many employees and physicians take the attitude of “that won’t work here.”

a. How should the organization respond? b. What would be different ways of implementing an initiative that could combat this

response?

3. Do you feel quality improvement is an easier process now that many healthcare organizations are utilizing an EHR? Why?

Activity 2

Use the chart forms linked in the assignment description on Canvas to complete this activity:

You are completing an internship in the Quality Department at General Hospital. As part of your internship, the director of the department has asked you to complete a small quality improvement project utilizing their EHR. The director would like you to determine if randomly selected five charts meet the following criteria:

• The consent is detailed and addresses the following 8 items: o Permission o Unforseen Conditions o Anesthesia o Specimens o Photographing, Videotaping, etc. o Explanation of Procedure, Risks, Benefits, and Alternatives o Blood Transfusion o No Guarantees

• All signatures required are present o Patient/Relative/Guardian o Physician o Witness

4-8. Record chart findings: (questions will be individual on quiz). All valid electronic signatures are denoted by an /es/ with the name of the individual signing and the date/time of the signature.

Question # Chart # Yes No

4. 1 5. 2 6. 3 7. 4 8. 5

9. Based on your findings from the 5 charts, what would be a goal for improvement (use the SMART goal format)?

Analyze the process and come up with your QI process (keep it simple)

10. Plan: 11. Do: 12. Check/Study: 13. Act:

Activity 3

You are the director of the Health Information Management Department of Hospital XYZ. The hospital has been using an EHR for 6 years and has been part of the Meaningful Use Incentive Program for 3 years. Part of your success has been the routine audits of medical records. The clinical staff is short-handed and has admitted to not being able to document as they used to as evidenced by the results of Activity 2. Your current staff of two are not able to meet the demands of auditing the charts and you will be hiring a third person to work with you. Among your many duties as manager is keeping policies and procedures up-to-date. Your team has composed the step by step process for a policy about auditing but after you review it you notice there are key elements missing that you as director must complete. The policy with the highlighted areas needed is located on the Modules page under this assignment (Critical thinking is required)

14. Title of policy 15. Purpose of auditing 16. Individuals responsible for documenting clinical information in the medical record 17. Individuals responsible for auditing the medical record to ensure documentation is complete

18. Definitions – do not define, just list the words from the policy that should be defined