Pediatric Inpatient Problem List Review and Accuracy Improvement

Abstract

BACKGROUND AND OBJECTIVES: The problem list (PL) is a meaningful use-incentivized criterion for electronic health record documentation. Inconsistent use or inaccuracy of the PL can create communication gaps among providers, potentially leading to diagnostic delays and serious safety events. The objective of the study was to increase the rate of PL review by attending physicians for inpatients discharged from hospital pediatrics and infectious disease services from a baseline of 70% to 80% by June 2018 and to sustain the rate for 6 months. The secondary aim was to improve PL accuracy by decreasing the rate of duplicate codes and red code diagnoses that should resolve before discharge from a baseline of 12% and 11%, respectively, to 5% and sustaining the rate for 6 months. METHODS: A quality improvement team used the Institute for Healthcare Improvement Model for Improvement. We tracked duplicate codes and red codes as surrogate markers of PL quality. Rates of PL review and PL quality were analyzed monthly via statistical process control charts (p-charts) with 3-s control limits to identify special cause variation. RESULTS: PL review improved from a baseline of 70% to 90%, and the change was sustained for 1 year. PL quality improved as duplicate codes at the time of discharge decreased from 12% to 6% and as red codes decreased from a baseline of 11% to 6%. CONCLUSIONS: The PL is an important communication tool that is underused. By engaging and educating stakeholders, incentivizing compliance, standardizing PL management, leveraging electronic health record enhancements, and providing physician feedback, we improved PL meaningful use and quality.

Identifying Children in Foster Care and Improving Foster Care Documentation in Primary Care

“…difficulties keeping them current. 30,33,34 Our study similarly noted that FC often remained on the patient's PL even after they exited FC. While there is a benefit in knowing a patient has a prior history of being in FC (eg, offering trauma-informed supports), providers should carefully review the PL at each encounter to ensure medical and psychosocial issues are appropriately updated.…”

“…This shift in culture and practice behavior is demonstrated not only by the improved documentation years after the active intervention, but also by the spillover effect observed in documenting FC status for children in other counties. Although prior studies similarly show that educating providers, [30][31][32] standardizing processes, 30,31 and selecting clinic champions 32 are effective methods in PL improvement initiatives, there were additional factors that contributed to the sustained success. Such factors included adding a FC section to the clinic handbook (See document, Supplemental Digital Content 1, which shows summary information included in the ambulatory clinic handbook referencing caring for patients in foster care and SmartPhrases to use in documentation.…”