一种质量改进的方法,以改善排放文档.
Sumeet L Banker1, Divya Lakhaney1, Benjamin S Hooe1
1From the Division of Critical Care and Hospital Medicine, Department of Pediatrics, Columbia University Irving Medical Center, New York, N.Y.
Pediatric quality & safety
|April 8, 2024
概括
改善医院出院摘要对于患者护理过渡至关重要. 这项研究加强了诊断和药物等关键要素的文档,显著提高了完成率.
科学领域:
- 改善医疗保健质量 改善医疗保健质量
- 患者安全 患者安全
- 临床信息学是一种临床信息学.
背景情况:
- 准确的医院出院摘要对于安全的患者护理过渡至关重要.
- 许多出院摘要缺乏基本内容,包括诊断,药物和后续计划.
- 需求评估发现了三个关键排放要素的文档缺口.
研究的目的:
- 提高儿科出院总结中基本要素的完成率.
- 增加20个百分点的出院诊断,药物和后续预约的文件.
- 在16个月的时间内实现持续改善.
主要方法:
- 利用计划-做-研究-行动 (PDSA) 周期进行代改进.
- 专注于增强提供者知识,澄清巡回期间的沟通,并优化电子健康记录.
- 随机选择并分析了每两周一次的10份出院摘要.
主要成果:
- 实现了完整的放任总结的显著增加,从45%增加到73%.
- 改善了出院诊断 (65%至87%),出院药物 (71%至90%) 和后续预约 (88%至93%) 的文档化率.
- 没有观察到对完成放电总结的及时性产生不利影响.
结论:
- 提供者教育,改进的沟通工作流程和EHR优化有效地提高了出院摘要.
- 这些干预措施导致文档质量的有意义和可持续的改善.
- 通过有针对性的质量改进策略,可以优化排放总结.
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