Use of Macros for Improvement of Speed and Quality: Ensuring Accurate and Timely Patient Documentation

This study hopes to increase the speed and quality of resident documentation at GW Hospital by expanding the use of macros at George Washington University Hospital’s general cardiology service. The project will focus on medical residents who are rotating on the Gold Team service (general cardiology service). A baseline survey was recently administered to query residents regarding time spent on writing comprehensive discharge instruction sheets for patients, self-assessed quality of discharge instructions written, and baseline use of macros templates. Macros templates for discharge instructions for the most common Gold Team diagnoses (heart failure exacerbation, non-cardiac chest pain, myocardial infarction, and syncope) will be composed by the study investigators under guidance and approval from cardiology attendings. The principle investigators will also compare discharge instructions before and after the intervention by randomly selecting 4 discharges per each of 8 Gold Team residents at baseline, and 4 discharges per each of 8 Gold Team residents during the intervention period. The instructions will be graded using a standard discharge grading form that is currently used in the Department of Medicine discharge clinic for rotating residents and has been validated in the literature. Each discharge instruction sheet will be graded by both investigators, and discrepancies will be resolved by discussion to consensus

Electronic Medical Record Discharge Template Use Improves Resident Efficiency

George Washington University internal medicine residents are challenged to deliver evidence-based, humanistic, and high-quality medical care. However, much of their time is spent on documentation instead of direct patient care or scholarly activities. The introduction of electronic medical records (“EMR”) has provided an opportunity for the improvement of both efficiency and quality of patient care. In reality, capitalizing on this opportunity has been particularly difficult in academic settings that experience high patient turnover and employ resident physicians at varying levels of training. The discharge instruction (“DCI”), which details the reason for a patient’s hospitalization, is among the most important documentation that a resident is responsible for. Despite this, only 16% of internal medicine residency programs have a discharge planning curriculum. This was addressed in a prior quality improvement (“QI”) project at George Washington University. The results of that project showed that DCI standardization through the use of templates led to a decrease in drafting time in addition to an increase in quality. Subsequently, the EMR system at the site of the project was changed. The present QI project aimed to adopt those previous instructions and replicate those results in the new system. Our aim was to increase the use of DCI templates by 25% in 4 months on the cardiology service. Templates were created for common diagnoses: acute heart failure exacerbation, syncope, noncardiac chest pain, and acute coronary syndrome. Initially, only 35% of respondents were using templates, however, after our final PDSA cycle 100% of respondents were using templates. This increase in use correlated with a decrease in the amount of time spent writing DCIs. The number of residents able to complete discharge instructions in less than 10 minutes increased by 28%. Despite the decrease in time, residents surveyed did not perceive a reduction in quality. Our study shows that the use of DCI templates or macros increases efficiency while maintaining quality. This will permit residents to devote more time to other aspects of patient care as well as to their pursuit of knowledge. Further PDSA cycles can be target the creation of additional templates for the cardiology service, and the expansion of template use to other services