10 clinicians, 456 charts: How we tackled quality improvement as a team
By Dr. Casey Clarkson, FRCPC
Embarking on a quality improvement (QI) project to improve your own practice is one thing, but have you ever wondered how to go about QI as a team?
I’d like to share how a group of 10 clinicians examined 456 charts to implement a group QI project for Maintenance of Certification (MOC) Program Section 3 credits.
Our activity of choice was the Royal College’s Section 3 chart audit activity.
We learned many lessons, which I’ve outlined as generic tips below. These tips could apply to any specialty or subspecialty at the Royal College. I hope these prove helpful if you are looking to launch your own team QI project.
Reporting on key performance indicators
I belong to a group of geriatricians working at different sites in New Brunswick. Every year, we are asked by our institutions to report on key performance indicators. We do this by collaborating on a QI project as a group. We have chosen to focus on an indicator from a communications framework unique to our discipline called the Geriatric 5Ms: Mind, Mobility, Medications, Multi-complexity and what Matters Most.
For our most recent project, we chose the Mobility “M” and used retrospective chart review to explore whether we were appropriately promoting evidence-informed interventions for falls risk reduction in high-risk outpatients.
Here are some of the lessons we learned.
Defining a team problem statement
- Pick a focus that’s well documented in your charts: To get the most insight into quality of care, pick something that’s within your discipline’s wheelhouse but outside of your normal referral bias. We chose to look at falls risk reduction because it is an aspect of our care and expertise that we don’t normally focus on. We also thought it would be reasonably documented in our charts.
- Be prepared to deliberate over target metrics: Plan for lots of interesting discussion about what your target outcomes should be! We deliberated a lot on how many interventions were reasonably demonstrative of good quality care. What would a good geriatrician do, realistically speaking, versus the best version of ourselves in a perfect world?
- Look at metrics that are relevant, meaningful and within your control: Choose to look at metrics that are unique to your discipline and reflect the actual value you bring to the table when it comes to patient care. For example, wait-time statistics would have been easy for us to measure, but are largely out of our control. How well we promote and communicate interventions is more indicative of the quality of care that we provide.
Documentation and bias
Although we were reassured to have hit many of our target outcomes, we did learn many lessons that I believe are useful reminders for all medical and surgical disciplines:
- The importance of adequate documentation: Some of our charts didn’t adequately document a history of falls or our recommended interventions to reduce them. This made it challenging to know if we’d missed opportunities to intervene.
- The discovery of our intervention bias: It was enlightening to see the spread and relative emphasis that we placed on certain interventions for reducing the risk of falls (such as exercise, gait aid advice and medication adjustments) versus others (like vision and foot-based interventions) that we promoted less frequently.
The results of this QI exercise gave us an opportunity to reflect on how we might approach documentation differently and better represent other equally important and evidence-based interventions in the future.
In conclusion, using retrospective chart reviews for team-based QI is a great strategy. I would highly recommend it to any group of physicians and surgeons looking to provide better patient care while meeting institutional reporting requirements. I promise you it will inspire you to record your successes and will invigorate your practice to perform even better!
MOC guidance note from the Royal College
Visit our Essential Guidance on Quality Improvement webpage for support to start reporting your own continuous quality improvement projects! Stay tuned for more QI tools and resources coming later this year, including additional support for how to define problem statements.
- For this improvement project, Dr. Clarkson and her colleagues who worked on the falls risk reduction project can claim MOC credits under “Section 3: Chart Audit and Feedback.”
- For the time spent on this project, Dr. Clarkson claimed 10 hours, which equated to 30 credits within Section 3. This time included chart reviews, spreadsheet design, data entry and analysis, and reflecting on the project.
- Other geriatricians who took part claimed approximately two hours (six credits) on chart reviews only.
Project participants can also claim other learning stimulated by this work under “Section 2: PLP” with sub-option “Addressing clinical or academic questions across the CanMEDS Framework” for two credits/hour.
Estimated time to report in MAINPORT: 5 minutes
For more information
Chart Audit and Feedback: Learn more about the Royal College’s guidelines for completing and reporting chart audits as Section 3 assessment activity.
The Geriatric 5Ms: Explore this innovative aide-memoire designed to better communicate the “geriatric giants” — core competencies that best reflect the expertise of geriatricians and family physicians with training in care of the elderly.