臨床小児科研究ジャーナル

Effect of implementing a standardize process on the quality of discharge summaries

Eyad Al-Midani

Objective: To assess the compliance rate and overall quality of discharge summaries among KFSH & RC patients according JCIA standards, during three years. Methods: A multidisciplinary team formulated, including the Quality director in the department of pediatrics as a chair person, the chairman of the department of pediatrics, the chief resident, a representative from medical records, a representative from the quality management, a representative from the information technology department and a representative from the medical and clinical affairs. An analysis of the situation as well as an explanation of the project idea was discussed with all team members and the process was built up as following: (See appendix 1) Results: Between the first quarter of 2011 and the first quarter 2014, a significant drop in the number of delinquent records have been documented where it was 1131 at the end of the first quarter of 2011 and dropped down to 68 records at the end of the second quarter of 2014. as well as the compliance to the JCIA standards which represent the documentation quality that has been audited by the hospital quality management department using a random, retrospective audits for 20 charts selected from the ICIS and reported on quarterly basis It shows improvement from 70% in the first quarter of 2013 up to 79% in the first quarter of 2014, and 86% in the second quarter of 2014, making the department of pediatrics ranking the first position across the hospital in comparison to the other department in regard to the quality of the discharge summaries. Conclusions: It is been found that by implementing a systematic framework in building up a discharge summaries for the patients will lead to a better quality of documentation and will minimize unnecessary delay. Comprehensive and precise clinical documentation improves the quality of patient care as well as the health information that is critical for ideal management of the health care system.