CHECKING THE CHARTS Do incomplete charts have your pre-admission nurses perpetually playing catch-up?

When your first case misses its scheduled start time, you can be sure that the rest of the day will be nothing but delays. Why was our same-day surgery unit seeing this situation over and over again? We didn't have to do much investigating to see that our chaotic pre-admission charting process was to blame. Missing test information and incomplete pre-procedure orders resulted in delays, downtime and last-minute reworks that frequently postponed, rescheduled or canceled cases.

We'd started by job-shadowing the same-day surgery nurse, who complained that when she received patients' charts on the day of the procedure, she occasionally had to scramble for missing information. Hours before surgery and charts were still missing lab tests or H&Ps, necessitating a call to the anesthesiologist or surgeon to fill in the blanks.

Then we stepped back to the anesthesiologist's review at noon on the day before surgery. Even more of the charts were missing tests and histories. Have you ever witnessed the distress of an anesthesiologist assessing an incomplete chart for patient safety? Suffice it to say, he'll affix a red dot to the chart and send it back to the pre-admission testing (PAT) nurse and secretary who assembled it, with orders to track down the details ASAP.

Root causes
It's not the PAT department's fault, and it's no wonder they often feel frustrated and unable to catch up. They're surrounded by charts covered with dots and notes. When pre-procedure orders arrive 96 hours before surgery, up to 60% are missing test results. The results and patient interviews come in randomly, at different times — sometimes as late as the night before surgery — requiring them to repeatedly locate and update charts.

We discovered a huge obstacle here. The PAT nurse's main sources of information in assembling the charts were the surgeons' pre-procedure testing orders. But each surgeon's office manager used different forms and filled them out differently, illegibly, incompletely or not at all. This required additional e-mails and calls to clarify the orders. Adding to the inefficiency, the surgeons' offices usually waited for PAT to let them know that test information was missing, instead of sending it over when they had it in hand. So more time and effort was wasted as the nurse and secretary contacted the office, and sometimes testing locations, multiple times, day after day, to round up the information needed for every chart.

Solution in sight
We'd still get the job done, but the mad scramble that was sometimes required to get a patient to the OR was unnecessary. Our team of staff and physicians sought to achieve 100% chart readiness by 6 p.m. on the night before surgery. Three improvements would help us reach that goal.

1. Standardizing the work. We met with surgeons' office managers to develop a standard pre-procedure order form and to ensure they'd all complete it the same way with the same information in the same places. (Note: You get a lot of volunteers to help you reach your process goals if you provide lunch.) Before we were done, the PDF file saw 25 revisions, each of which was reviewed by our PAT nurse.
2. Making progress visual. Information needs to be collected within a certain time frame to prepare a chart, and a patient, for surgery. We built an interactive internal website, the PAT Tracker, so all the players in the process can monitor what information is missing in real time, at any time.
3. Communicating completion. Automated daily backlog reports with hyperlinks to the website's case details are e-mailed internally to alert physicians and staff to missing information. HIPAA concerns prevent us from granting website access to external surgeons' offices, but we send out secure e-mails to each.

Online admissions
Our results have been impressive, with double-digit reductions in the incidence of missing H&Ps, consults, consents and EKGs. But the best evidence that it's made our workflow more efficient is that our patients have on average been arriving in the ORs 20 minutes earlier.

When we shopped around for our next EMR, we asked the vendors' reps how their products might help solve the snags we identified during our review. We recommend finding out what doesn't work in your charting process before taking it electronic.

In the future, we hope to create a virtual registration process in which patients complete their medical histories online, entering all demographic and insurance information. Insurance verification would occur behind the scenes and communications would be sent to patients with their expected deductible and/or co-insurance. They'd then be prompted to either make a payment or set up a payment plan electronically. All of the other forms that we ask patients to sign or acknowledge on the day of surgery would be reviewed and acknowledged online. Mobile messages would direct patients as to what actions they need to take and when, and would tell them when to arrive. On the day of surgery, they'd be greeted by a member of the clinical staff. OSM