'Write Right': the GSAHS clinical documentation project.
Abstract: The Clinical Documentation Project was piloted at one site in Greater Southern Area Health Service (GSAHS) in New South Wales; it aimed to improve the standard of clinical documentation by 50% between March and August 2005. The main intervention was the use of a Self Directed Documentation Learning Package (SDDLP). Results achieved a 75% improvement in clinical documentation within six months and a 46.5% improvement in clinicians' confidence in their level of knowledge on documentation requirements.

Keywords (MeSH): Medical Records; Patients; Safety; Methodology; Clinical Governance
Article Type: Report
Subject: Documentation (Management)
Medical records (Management)
Medical informatics (Management)
Medical care (Quality management)
Medical care (Management)
Patients (Care and treatment)
Patients (Management)
Authors: Stewart, Ann
Robben, Tony
Pub Date: 10/01/2010
Publication: Name: Health Information Management Journal Publisher: Health Information Management Association of Australia Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Health Information Management Association of Australia Ltd. ISSN: 1833-3583
Issue: Date: Oct, 2010 Source Volume: 39 Source Issue: 3
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Geographic: Geographic Scope: Australia Geographic Code: 8AUST Australia
Accession Number: 241781521
Full Text: To improve the safety and quality of patient care the Clinical Governance Unit in the Greater Southern Area Health Service (GSAHS) in New South Wales, an area-wide project was launched to assist these facilities to improve the standard of their clinical documentation. The project was captioned 'Write Right'. The aim of the project was to improve the standard of clinical documentation by 50% at one pilot hospital between March and August 2005, and to then spread the process to the remaining 47 hospitals, 95 community health/ community outreach centres across GSAHS by June 2006.

The Emergency Department (ED) Documentation Collaborative was a precursor to the 'Write Right' Project, with results after 12 months showing an average improvement of 24% across six hospitals, with one facility achieving 53% improvement. The success of this project encouraged the development of a self-directed learning package used in the ED project into a generic documentation package and to then pilot the package at one hospital.

Evidence was sought to determine the need to spread the project across the health service and identified the following:

* Research of literature indicated a relationship exists between safe patient outcomes and quality documentation (Laudermilch et al. 2010; Maloney 1999).

* A pilot audit of ED and ward-based documentation highlighted improvement was needed.

* A review of complaint and medicolegal cases highlight the need to improve documentation; that is, solicitors defending a lawsuit against Greater Southern Area Health Service were not able to build a defence due to the paucity of documentation, which resulted in significant payment to the plaintiff. Review of medical records following receipt of patient complaints identified insufficient documentation to enable the facts to be established around the alleged concerns expressed.

* Recommendations from Root Cause Analysis (RCA) processes identified the need to improve clinical documentation.

Results of the pilot study were presented to the GSAHS Quality Council and the Chief Executive, who endorsed the project and supported its spread to all sites, services and clinicians within the Area Health Service. Executive sponsors were identified to support the project and to assist in overcoming any barriers encountered. A multidisciplinary project team was formed and consultation undertaken with nursing, allied health, medical officers, managers, clinical nurse consultants, health information staff, clerical staff and patient comment was sourced via the GSAHS Quality Committee and the hospital/service Cluster Quality Committees. Marketing to managers occurred via memoranda, initially to gain support for implementation, followed by introduction and marketing to clinicians through meetings and the GSAHS Bulletin (2). The 'Write Right' logo was designed to provide a visual and readily identifiable image for the project and was widely used on all promotional correspondence, project documents and other material relating to the project.

When the Continuous Process Improvement (CPI) methodology (Van Matre 2004) was used to implement the project at health facilities, greater gains resulted, and there was also an increased likelihood of sustainability compared with facilities that did not use CPI processes. CPI methodology was used at the pilot site and it was recommended that other sites use this approach. CPI methodology includes brain-storming with clinicians to identify causes and possible solutions to substandard documentation. Flow charts of the documentation process were developed and the causes and effects of poor documentation identified. The causes were prioritised using the Pareto Principle (20% of causes create 80% of the problem) to achieve the greatest benefit by targeting the biggest problems.

Regular evaluations were undertaken throughout the process by auditing medical records to determine whether the changes implemented had resulted in improvement. Regular analysis of results and feedback to staff was provided and served as positive reinforcement, as well as an avenue for further encouragement. Sites choosing not to use CPI methodology were asked to attend a baseline medical record audit, to distribute the SDDLP (Leaver, Robben & Stewart 2005) and to follow up with a post audit to identify any improvement.

The Project Team sought new solutions to break the identified barriers to effective education (time, funds, distance) for clinicians in rural NSW and agreement was reached on a multi-faceted approach:

* Former Area Health policy on documentation to be reviewed and developed into:

** GSAHS Clinical Documentation Policy

** GSAHS Clinical Documentation Guidelines

** GSAHS Emergency Department Documentation Guidelines.

* Development of a documentation audit tool.

* Development of generic Self Directed Documentation Leaning Package (SDDLP) for nursing and allied health clinicians including:

** pre and post knowledge tests on clinical documentation;

** learning module covering all aspects of documentation

** appendices of

--GSAHS documentation policy and guidelines

--Mandatory NSW Health policy directives and circulars pertaining to documentation in health records.

* Packages distributed by local management.

* Refinement of the ED SDDLP into a supplement.

* Development of Emergency Department Documentation and Clinical Documentation Principles for Medical Practitioners - SDDLP and mailed to 966 doctors.

* Development of a Manager's Resource Kit including:

** instructions on use

** user guides for evaluating SDDLPs/audits

** template letter for staff

** 'Write Right' posters

** Quick Guide sheet for display in clinical areas

** design of a template Certificate of Completion.

* CPI training to 167 staff across GSAHS (15 workshops); presentation of pilot project and education on use of 'Write Right' tools.

The 'Write Right' project resulted in important and significant outcomes for individual clinicians, health facilities and services and for GSAHS, including:

* Provided a review and implementation of documentation policy and guidelines.

* It assisted sites in meeting ACHS Accreditation requirements; that is, health records must be reviewed, meet medico-legal requirements and appropriate standards and guidelines.

* It enabled specific sites and units to meet RCA recommendations.

* Discipline specific SDDLPs and ED supplement proved valuable in content and ability for use at clinician's leisure and achieve quantifiable learning.

* It provided effective education in a rural setting where other traditionally used methods had failed in terms of outcomes, cost effectiveness and access to high numbers of clinicians including medical officers.

* Sites using CPI methodology achieved greatest improvement, the most likely reason being greater ownership of the process and implementation of additional interventions in response to identified local need.

* CPI training was provided to 167 staff through 15 workshops, with the additional benefit of teaching the CPI methodology that can be used in future improvement projects.

Results achieved included:

* A survey of clinicians at the pilot site rated the effectiveness of SDDLP as a tool to achieve improved documentation as 94% positive.

* Individual level of confidence in their knowledge about the requirements for quality documentation requirements was improved by:

* nurse/allied health (29%)

* medical officers (51%).

* ED documentation improved by 68%.

* Clinical documentation in hospitals and community health settings improved by 49%.

* Sustainability was proven at the pilot site with total improvement being a 75% gain from initial baseline audit of medical records. A subsequent audit demonstrated a further 53% improvement on this result.

A further audit of medical records undertaken at the pilot facility four years after completion of the project (December 2009), demonstrated extended sustainability with 85% compliance with documentation requirements. Investigation of the reasons for this indicated that despite the significant staff changes that had occurred to management and clinicians, the SDDLP was used and referred to regularly. The SDDLP was provided to all new employees and individual clinicians where it was identified through review processes that development of their standard of documentation was required. This result further demonstrated the use of the SDDLP as a stand-alone tool to be effective.

To ensure sustainability beyond the scope of the project, the SDDLP was introduced into the GSAHS Orientation and Mandatory Education Programs. There are hopes for the SDDLP and record audit processes to be developed into a web-based e-learning process and used as an aspect of a regular credentialing process.

The material and methodology used for this project has been shared nationally and internationally with 85 organisations.

Acknowledgements

Acknowledgement is given to members of the project team, in particular Dr Trish Saccasan-Whelan and Diana Leaver.

References

Laudermilch, D.J., Schiff, M.A., Nathens, A.B. and Rosengart, M.R. (2010). Lack of emergency medical services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care. Journal of the American College of Surgeons 210 (2): 220-227. Available at: http://www. journalacs.org/article/S1072-7515(09)01490-2/abstract (accessed 4 July 2010).

Leaver, D., Robben, A. and Stewart, A. (2005). Greater Southern Area Health Service Self Directed Documentation Learning Package. Queanbeyan NSW, Australia, Greater Southern Health Service.

Maloney, R. (1999). A systemic review of the relationship between written manual nursing care planning, record keeping and patient outcomes. Journal of Advanced Nursing 30 (1): 51-7.

Van Matre, J.G. (2004). Continuous quality improvement (CPI). In M.J. Stahl (Ed.) Encyclopedia of health care management (pp. 102-103). California, Sage. Available at: http://books.google. com.au/books?id=LOuWpYALeM0C&pg=PA103&lpg=PA103& dq=Continuous + Process + Improvement+Brent+James&sourc e=bl&ots=3s3gKirR7W&sig=cVDN_SU3B4kbiUp1pU7DW-1vV dI&hl=en&ei=imQyTOSoD8O5cZrRqMoH&sa=X&oi=book_r esult&ct=result&resnum=7&ved=0CCQQ6AEwBg#v=onepag e&q=Continuous%20Process%20Improvement%20Brent%20J ames&f=false (accessed 4 July 2010).

Ann Stewart, RGN, RM, GradCertQI, FLECcert, ImmuCert

Acting Director Clinical Governance

Greater Southern Area Health Service

34 Lowe Street

Queanbeyan NSW 2620

AUSTRALIA

Tel: +61 2 6124 9820

email: Ann.Stewart@gsahs.health.nsw.gov.au

Tony Robben, RGON, AdvDipN, BSci, GradCertMgt,

GradCertQI

Acting Professional Practice Manager

Greater Southern Area Health Service

34 Lowe Street

Queanbeyan NSW 2620

AUSTRALIA

Tel: +61 2 4475 1647

email:Tony.Robben@gsahs.health.nsw.gov.au

(1) This project has been presented at the following conferences: The Royal College of Nursing, Australia Annual Conference, July 2006; 4th Australian Conference on Safety and Quality in Health Care, Melbourne, August 2006; The Clinical Documentation, Coding & Analysis Conference March 18, 2010.

(2) The Bulletin is available to staff only via the Intranet
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