Using a hospitalwide performance improvement process for patient education documentation

Decreases in length of hospital stay have increased pressure on staff to provide appropriate patient education. A hospitalwide continuous quality improvement (CQI) program was implemented to improve patient education documentation at Raritan Bay Medical Center (RBMC; Perth Amboy, NJ). IMPROVING THE PATIENT EDUCATION DOCUMENTATION PROCESS: In March 1995 the patient education committee was given the responsibility to develop a CQI program to improve documentation of patient education. Patient interviews revealed that assessment of patients' initial knowledge was inadequate and goal setting was omitted. The committee developed generic and disease-specific patient education documentation forms for educational assessment and patient education. The patient chart was reconfigured to include a central location for patient education.

A review of almost 900 patient records established that the percentage of records on which patient education was documented had improved from 41% in summer 1995 to 93% in fall 1996, with an improvement across all disciplines. A follow-up review in fall 1997 of 136 randomly chosen records indicated a slight decrease in rate of documentation of content areas, although nursing services and nutritional care continued to maintain their patient documentation education at a rate of > or = 90%.

Factors such as providing continuous feedback on patient education documentation performance to all nursing units and disciplines involved, developing additional disease-specific education assessment plans/documentation tools through an interdisciplinary process, and improving the data collection tool after each measurement period all contributed to improved patient education documentation.

Patient education is now truly integrated at RBMC, with every pertinent discipline involved in decision making throughout the process of continuously improving the patient education process and documentation.