Reformation Project

South Eastern Sydney Illawarra Area Health Service

This project was entered in the Baxter 2006 NSW Health Awards, Efficiency of Service Provision category.

 Presentation given at the 2006 NSW Health Expo by Renee Droguett.

Contact: Renee Droguett

Abstract

In response to a near miss incident in the Emergency Department (ED) and subsequent clinical forms audit the St George Hospital Reformation Project was conceived. It was realised that inefficiencies and inaccuracies in clinical forms have the potential to significantly impact on cost effectiveness, consistency, effective communication among health professionals and increased patient risk (J. Forbes 2005, Reformation Project Paper, 07 February).

Following a moratorium on all new forms being developed and suspension of the Forms Committee, the Project implemented a cost efficient Forms Management System that streamlined clinical forms processes and reduced the number of forms by 50%. Forms are now compliant with Australian Standards AS2828 - 1999 Paper Based Health Care Records (AS 2828). The consistency of the medical record has improved, providing a more effective communication tool used by health professionals, in turn minimising patient risk.

The Forms Management System has automated the clinical forms process and has far reaching benefits now, and into the future. It is a step towards Electronic Health Record (EHR) and is in line with New South Wales (NSW) Health Initiatives.

Aim

To develop and implement a sustainable and cost efficient Forms Management System, with a stretch goal of implementation by July 05.In addition, to standardise and reduce the amount of clinical forms by 50%.

Background

In 2003, a near miss was reported in the ED whereby a patient almost received a double dose of medication; the order was recorded on 2 separate forms. Investigation revealed medication could be ordered on multiple forms, increasing risk of errors of omission, or multiple doses given.

Further investigation by the Clinical Practice Improvement Unit (CPIU) involved a medical record audit. 583 forms were reviewed and compared against the Clinical Information Services - 'Order of Forms'. Results indicated 310 forms (53.2%) included in medical records were unidentified and unapproved, 154 (26.4%) current forms could not be obtained for audit, and 119 (20.4%) forms audited were consistent with the 'Order of Forms', however not all were current versions.

Further to this, the forms audited did not adhere to AS 2828, print quality was poor, clinical content of some forms was outdated, multiple versions were used extensively and there was a significant amount of duplication in information recorded.

A more sustainable cost effective Forms Management System was required.

Methodology

A project team was formed including the Project Head - Lead Clinician CPIU, CPIU Director, a Health Information Manager and a contractor from the University of Technology Sydney. Brainstorming with key personnel, Nursing Management, Heads of Departments, and Directors of Services within St George, as well as external agencies took place. This enabled the team to gain insight into the issues associated with clinical forms.

Clinical forms once audited were grouped into clinical areas. Customer focus groups were established accordingly: Midwifery, Renal, Patient Advocate, Cardiology, Surgery, Trauma, Pain Team, Medicine, Emergency Department, Respiratory, Allied Health, Discharge Planning, Paediatrics and Pharmacy.

Criteria were developed for rationalising forms, based on best practice and literature reviews, and were used by the customer focus groups to review forms.
Brainstorming and results of the audit identified issues associated with an inefficient Forms Management System. This information was used to develop a Cause and Effect Diagram.

Figure1: Cause and Effect Diagram

The 80:20 ratio of the Pareto Chart allowed us to prioritise Process, and Forms Content and Design as the areas to focus initially for greatest impact of improvement.
We then addressed remaining areas.

Planning and Implementation

The project team agreed on the structure and process of the Forms Management System. A time line was developed and interventions were implemented based on Plan Do Study Act (PDSA) cycles, which tested their effectiveness. These included:

• Establishing procedure for deletion of forms;
• Reformatting clinical forms according to AS 2828 and best practice;
• Barcoding clinical forms for identification and scanning purposes;
• Developing a register of clinical forms, available to staff accessible in hard (folder) and soft copy (intranet & CD);
• Developing an intranet site to:
• Provide a register of clinical forms;
• Facilitate viewing and printing of forms; and
• Linking policies and procedures relevant to specific forms;
• Establishing a Forms Manager Position;
• Re-establishing the Forms Committee;
• Implementing an updated Protocol for New/Revised Medical Record Forms;
• Re-introducing the Trial Forms Process;
• Updating 'Order of Forms';
• Establishing a Gate-keeping Process managed by medical record assembly clerks monitoring unauthorised forms being included in medical records.
• Strengthening processes between the Area Design and Print Department and St George Hospital; and
• Promoting the Forms Management System using email and intranet campaigns, Directives issued by the director of CPIU, letters to Nursing Management and Directors of Services.

Outcomes and Evaluation

A clinical forms audit in July 2005 measured the impact of the Forms Management System. Over 50% of forms were deleted leaving 223 forms audited. Of these, there were no (0%) unidentified, unapproved clinical forms. The implementation of the Forms Management System eradicated the problem of forms unable to be obtained for audit, these forms reduced from 151 to 0 (0%). 223 (100%) of clinical forms adhere to AS 2828. There are no multiple versions of forms, and there has there been a reduction in the amount of duplication.

A medical record audit in 2006 measured the success of implementation. The tangible outcomes included:

• 100% of records were consistent with the Order of Forms;
• 100% of forms are barcoded and identifiable to facilitate scanning;
• 100% of forms are compliant with best practice and AS 2828;
• 94% of records audited did not contain clinical forms that were deleted during the reformation project;
• 64% of records contained approved current trial clinical forms; and
• Automated intranet site with 233 (100%) clinical forms available to view online. The register has provided a tool whereby staff can access and review forms and amalgamate where possible to reduce duplication of information captured.

Intangible Outcomes include:

• Decreased printing costs by storing low usage forms on the intranet;
• Decrease costs by standardising forms and reducing the overall number of forms;
• Reducing staff time spent photocopying forms;
• Improved quality of the medical record has assisted medicolegal processes;
• Improved communication between clinicians;
• Improved medical record quality has improved patient risk;
• Improved access to clinical form information; and
• Linking of clinical forms to relevant NSW Health or Internal policy and procedures via the intranet.

Future Scope

The Forms Management System has improved clinical forms at St George Hospital. In addition, the South Eastern Sydney and Illawarra Area Health Service (SESIAHS) intends to adopt the system to streamline clinical forms processes across the Area. It is hoped the intranet site will not only facilitate links to policies and procedures, but may one day link clinical manuals and SESIAHS Policy and Procedures. Current formatting, barcoding and scanning of clinical forms under the new Forms Management System, is an early step to the development of an EHR and is in line with NSW Health Initiative.

References

Standards Australia 1999, Paper-based health care records, AS 2828-1999