Standardization of quality of diagnoses, interventions, and outcomes (Q-DIO) measurement instrument for use in Slovenia

Purpose To describe the cross-cultural adaptation of the Quality of Diagnoses, Interventions and Outcomes (Q-DIO) Instrument into the Slovene language. Methods Based on general international guidelines, a six-step process of localization to translate and adjust the instrument from English into the Slovene language was used. Content validity was quantified based on an agreement of eight experts. The instrument was tested using a sample of 140 nursing documentations from two Slovenian tertiary hospitals. Results 26 of 29 items showed an excellent content validity index ranging from 0.857 to 1.000, and a modified kappa index above 0.856. The content validity indexes of the three remaining items adjusted based on experts’ comments were subsequently estimated at 1.000. Construct validity was significantly different between the two groups of documentations. The Cronbach coefficient for the whole questionnaire was 0.860. Cronbach’s alpha if item deleted reamins above 0.80 for all items. The criteria for the difficulty grades of items and discrimination validity were acceptably met for more than 75% of items. Conclusion Based on the results of the study, it may be concluded that Q-DIO is a reliable instrument for measuring the quality of nursing documentation. The deviations in the results of some items are due to poor nursing documentation quality, and indicate that nursing classifications have not yet been fully implemented into practice in the study setting. Additional testing of the instrument is recommended.

Quality Assessment for National Libraries

National libraries as well as any other progressive institutions have to assess the results of their performance. Depending on the type, functions, structure, areas of activities, organizational and financial methods, any national library can test wide sets of performance indicators consistent with its mission. Those indicators may differ from the indicators being tested by other national libraries. Quite often national libraries can also use additional indicators if financial/sponsoring organizations or target user groups etc. require this.The paper considers the methods and procedures for measuring quantitative indicators of national libraries’ performance according to the new international standard ISO 21248:2019 “Information and documentation: Quality assessment for national libraries”, which is partially based upon the ISO 11620:2008 standard “Information and documentation. Library performance indicators”. The author presents specific examples for calculating indicators using formulas and detailed description of steps for calculation of indicators depending on the library mission and goals. Along with qualitative indicators, the new standard recommends to use qualitative indicators to assess the impact of national libraries not only on their users, but also on society as a whole. In recent years, libraries have developed and probated methods to justify their importance. One of those methods is user surveying by means of special questionnaires made on the basis of ISO 16439:2014 standard “Information and documentation. Methods and procedures for assessing the impact of libraries” and circulated by libraries among their users to educe and differentiate interests of different user groups to provide them with subsequent target service.

Quality of Design Documentation in the Construction Industry: A Review Using Meta-Synthesis Approach

A meta-synthesis approach was used to identify, synthesize, and categorize appropriately factors in the literature that contribute to design documentation quality. The categories include factors on quality attributes, quality indicators, and quality-influencing factors. Findings indicate that the quality of design documentation in practice is unsatisfactory, therefore, there is a need for collaboration between the owner, designers, and end-users to improve design documentation quality. The results offer pragmatic data on design documentation quality in the construction industry between the years 1992 and 2019. However, further research on the significant impacts of poor-quality design documentation on construction projects is recommended.

1126 Improving Hand Trauma Clerking Using an Electronic Proforma: A Full Cycle Clinical Audit

Aim The BSSH standards of care in hand trauma emphasise the importance of accurate and comprehensive documentation. This quality improvement project aimed to evaluate whether an electronic proforma could improve documentation rates in hand trauma. Method This prospective, closed-loop audit involved two cycles of seven consecutive days. Outcomes were evaluated against BSSH standards of care using 15 data points. Pre-audit, a bespoke proforma was piloted in the hand trauma clinic and revised following feedback. In the first cycle (‘Loop 1’), documentation in the hand trauma clinic was compared with that of the acute take, where clinicians were still using free text. The second cycle (‘Loop 2’) compared documentation pre- and post-introduction of the proforma within the acute take setting. Categorical data were interrogated using the χ2 test with significance set at p < 0.05. Results 122 patients were included in the Loop 1 dataset. Free text clerking quality varied between clinician groups (e.g., surgical trainees significantly outperformed advanced nurse practitioners in 5/15 data points); however, some data points were universally poorly documented. 99 patients were included in the Loop 2 dataset. There was excellent uptake of the proforma in both acute take (95%) and hand trauma clinic (100%) settings. Statistically significant improvements were seen in 11/15 data points following the introduction of the proforma. Conclusions This project demonstrates that the introduction of a hand trauma clerking proforma led to significant improvements in documentation quality. The proforma has now been developed into a Trust-wide ClinDoc which brings additional benefits in terms of research, audit and service evaluation.

Examining the Concordance in the Documented Pressure Injury Site, Stage, and Count in Medical Information Mart for Intensive Care-III

Objectives This study aimed to compare the concordance of pressure injury (PI) site, stage, and count documented in electronic health records (EHRs); explore if PI count during each patient hospitalization is consistent based on PI site or stage count in the diagnosis or chart event records; and examine if discrepancies in PI count were associated with patient characteristics. Methods Hospitalization records with the International Classification of Diseases ninth edition (ICD-9) codes, chart events from two systems (CareVue, MetaVision), and clinical notes on PI were extracted from the Medical Information Mart for Intensive Care (MIMIC)-III database. PI site and stage counts from individual hospitalization were computed. Hospitalizations with the same or different counts of site and stage according to ICD-9 codes (site and stage), CareVue (site and stage), or MetaVision (stage) charts were defined as consistent or discrepant reporting. Chi-squared, independent t-, and Kruskal–Wallis tests were examined if the count discrepancy was associated with patient characteristics. ICD-9 codes and charts were also compared for people with one site or stage. Results A total of 31,918 hospitalizations had PI data. Within hospitalizations with ICD-9-coded sites and stages, 55.9% reported different counts. Within hospitalizations with CareVue charts on PI, 99.3% reported the same count. For hospitalizations with stages based on ICD-9 codes or MetaVision chart data, only 42.9% reported the same count. Discrepancies in counts were consistently and significantly associated with variables including PI recording in clinical notes, dead/hospice at discharge, more caregivers, longer hospitalization or intensive care unit stays, and more days to first transfer. Discrepancies between ICD-9 code and chart values on the site and stage were also reported. Conclusion Patient characteristics associated with PI count discrepancies identified patients at risk of having discrepant PI counts or worse outcomes. PI documentation quality could be improved with better communication, care continuity, and integrity. Clinical research using EHRs should adopt systematic data quality analysis to inform limitations.

Evaluation of comprehensiveness and reliability of electronic health records concerning resuscitation efforts within academic intensive care units: a retrospective chart analysis

Background According to the literature, the validity and reliability of medical documentation concerning episodes of cardiopulmonary resuscitation (CPR) is suboptimal. However, little is known about documentation quality of CPR efforts during intensive care unit (ICU) stays in electronic patient data management systems (PDMS). This study analyses the reliability of CPR-related medical documentation within the ICU PDMS. Methods In a retrospective chart analysis, PDMS records of three ICUs of a single university hospital were searched over 5 y for CPR check marks. Respective datasets were analyzed concerning data completeness and data consistency by comparing the content of three documentation forms (physicians’ log, nurses’ log, and CPR incident form), as well as physiological and therapeutic information of individual cases, for missing data and plausibility of CPR starting time and duration. To compare data reliability and completeness, a quantitative measure, the Consentaneity Index (CI), is proposed. Results One hundred sixty-five datasets were included into the study. In 9% (n = 15) of cases, there was neither information on the time points of CPR initiation nor on CPR duration available in any data source. Data on CPR starting time and duration were available from at least two data sources in individual cases in 54% (n = 90) and 45% (n = 74), respectively. In these cases, the specifications of CPR starting time did differ by a median ± interquartile range of 10.0 ± 18.5 min, CPR duration by 5.0 ± 17.3 min. The CI as a marker of data reliability revealed a low consistency of CPR documentation in most cases, with more favorable results, if the time interval between the CPR episode and the time of documentation was short. Conclusions This study reveals relevant proportions of missing and inconsistent data in electronic CPR documentation in the ICU setting. The CI is suggested as a tool for documentation quality analysis and monitoring of improvements.

Bridging the gap: improving liaison psychiatry documentation quality to meet the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) treat as one recommendations at newcastle hospitals

AimsThis project aimed to assess and improve the quality and frequency of documentation from Psychiatric Liaison Team (PLT) to ward-based medical colleagues against the Treat as One recommendations. From experience, we hypothesised that written documentation of information crucial to patient care is not consistently meeting standards. This communication breakdown directly affects patient safety, potentially introducing additional risks to our already vulnerable patient group.Effective communication between PLT and our medical colleagues bridges the gap in providing continuity of care and ensures patients’ mental and physical health needs are met in acute trusts. The NCEPOD found that there remains many barriers to high quality mental healthcare provided to patients in general hospitals and recommended 7 elements that PLT documentations should encompass.MethodWe audited initial PLT assessments and the resulting documentation to determine if these met the 7 standards set by NCEPOD. Baseline audit undertaken from 21-27/09/2020 encompassing 130 patient referrals to PLT.A period of time was allotted to implement robust changes to improve the service. This included a streamlined e-template that automatically populates in the acute hospital eRecord system which prompts clinicians to document according to the NCEPOD standards, structured clinician training and education, and the nomination of “Treat as One Guardians” in the team to ensure that acute trust documentations are present during daily multidisciplinary meetings.The cycle was then completed on 22-28/02/2021 with a re-audit capturing 55 referrals.ResultImplementation of our recommended changes saw an increase from 58% of documentations with ≥50% NCEPOD elements to 98% in the re-audit.We also saw an increase in number of the NCEPOD 7 elements included following intervention: formulation (0% to 8%), legal status and capacity (47% to 79%), risk assessment (2% to 28%), risk management (18% to 53%), and discharge plan (2% to 29%).Completion rate of acute trust documentation increased from 74% to 96%.Our interventions also led to more contemporaneous communication, significantly reducing mean time from assessment to documentation in both acute trust and mental health records from 6.02 to 3.53 hours, (p = 0.04) and 6.12 to 3.50 hours, (p = 0.05) respectively.ConclusionFollowing our interventions, the results showed improving trends in the frequency and quality of our documentation with secondary outcomes showing increased documenting efficiency. Our current practice is not yet optimal and retains potential to adversely affect our patients. We propose further investigating barriers to change using the quality improvement PDSA (Plan, Do, Study, Act) methodology to continue innovating.

Advance care planning billing practices and documentation quality for cancer patients requiring hospitalization.

e24000 Background: Advance Care Planning (ACP) is an important component of comprehensive cancer care, yet barriers exist to successful implementation. In 2016, Medicare introduced billing codes to provide reimbursement for ACP discussions. Our aim was to evaluate the usage of ACP billing codes and quality of accompanying documentation in patients with a prior oncology admission at an academic medical center. Methods: Using an electronic health record data warehouse tool, we identified a cohort of cancer patients who had been admitted to the inpatient oncology service and had an ACP billing encounter (CPT codes 99497 or 99498) over a 4-year period (8/1/2016 to 8/1/2020). We collected patient and provider demographics and performed descriptive statistics. We assessed ACP documentation quality for 30 patients selected at random based on 5 domains (healthcare proxy, health values or goals, scope of treatment/code status, prognosis/illness understanding, and end of life [EOL]care planning/hospice) previously identified from a literature review. Results: We identified 170 unique patients (180 ACP encounters), representing a small fraction (170/5636, 0.03%) of hospitalized oncology patients over the study period. Patients were 52% female with mean age of 64 (SD 12.9). Mean number of oncology hospitalizations was 2.6 (SD 1.96). ACP encounters took place in both inpatient (135/180; 75%) and outpatient (45/180; 25%) settings. In the outpatient setting, the majority of billing encounters were in palliative care (27/45; 60%), followed by oncology (12/45;27%) and primary care (5/45;11%). Of the sample of patient charts reviewed (n = 30), provider documentation frequently included scope of treatment (27/30; 90%), prognosis (27/30; 90%), EOL planning (21/30; 70%), and health values (19/30, 63%); healthcare proxy was infrequently included (4/30, 13%). Conclusions: ACP billing remains infrequently utilized for a cohort of oncology patients requiring hospitalization at a large academic center. In cases for which an ACP discussion is billed, the accompanied documentation is of high clinical utility and meets several key quality domains. This work lays a foundation for future research and quality improvement efforts to improve ACP and documentation.[Table: see text]

The frequency and quality of delirium documentation in discharge summaries

Background The National Institute for Health and Care Excellence recommends documenting all delirium episodes in the discharge summary using the term “delirium”. Previous studies demonstrate poor delirium documentation rates in discharge summaries and no studies have assessed delirium documentation quality. The aim of this study was to determine the frequency and quality of delirium documentation in discharge summaries and explore differences between medical and surgical services. Methods This was a multi-center retrospective chart review. We included 110 patients aged ≥ 65 years identified to have delirium during their hospitalization using the Chart-based Delirium Identification Instrument (CHART-DEL). We assessed the frequency of any delirium documentation in discharge summaries, and more specifically, for the term “delirium”. We evaluated the quality of delirium discharge documentation using the Joint Commission on Accreditation of Healthcare Organization’s framework for quality discharge summaries. Comparisons were made between medical and surgical services. Secondary outcomes included assessing factors influencing the frequency of “delirium” being documented in the discharge summary. Results We identified 110 patients with sufficient chart documentation to identify delirium and 80.9 % of patients had delirium documented in their discharge summary (“delirium” or other acceptable term). The specific term “delirium” was reported in 63.6 % of all delirious patients and more often by surgical than medical specialties (76.5 % vs. 52.5 %, p = 0.02). Documentation quality was significantly lower by surgical specialties in reporting delirium as a diagnosis (23.5 % vs. 57.6 %, p < 0.001), documenting delirium workup (23.4 % vs. 57.6 %, p = 0.001), etiology (43.3 % vs. 70.4 %, p = 0.03), treatment (36.7 % vs. 66.7 %, p = 0.02), medication changes (44.4 % vs. 100 %, p = 0.002) and follow-up (36.4 % vs. 88.2 %, p = 0.01). Conclusions The frequency of delirium documentation is higher than previously reported but remains subpar. Medical services document delirium with higher quality, but surgical specialties document the term “delirium” more frequently. The documentation of delirium in discharge summaries must improve to meet quality standards.

450 Retrospective Analysis of Surgical Clerk-Ins Within the Acute Receiving Unit: A Quality Improvement Project

Introduction Accurate patient documentation at the ARU is vital to patient safety and ensuring smooth handovers to secondary care services. Because the nature of surgical treatment requires frequent patient handovers, and this increases the risk of miscommunication, we aimed to assess the quality of surgical clerk-ins and identify areas for improvement. Method Emergency admissions at the Dumfries Galloway Royal Infirmary were audited, looking at documentation quality under various clerk-in sections. Data was analysed before presentation to clinical governance. Results When 46 patient clerk-ins were examined, venous thromboembolism (VTE) prophylaxis plans were performed in only 24% of admissions - less than 1 in 4 patients. Comparing out-of-hours and in-hours patient documentation, much higher omission rates were identified in the out-of-hours documentation: in systemic enquiry (42 vs 100%) and family history (31% vs 66%). Conclusions These results brought to attention the effect of hospital admission timing on patient documentation quality, and the lack of VTE prophylaxis planning. In surgery, these plans are key to minimising risk of avoidable thromboembolic complications. A departmental meeting was convened to stress the importance of accurate and comprehensive clerk-ins to ARU doctors. Future audits could explore the factors influencing documentation quality for out-of-hours admissions, and ways to address these issues.