Aligning complex processes and electronic health record templates: a quality improvement intervention on inpatient interdisciplinary rounds

Hilary J. Mosher, Daniel T. Lose, Russell Leslie, Priyadarshini Pennathur, Peter J. Kaboli

Interdisciplinary rounds (IDR) with documentation have become a standard of care, but the process has been incompletely described in academic general medical settings. Checklists are promoted, yet standardized formats may not reflect the variability and work flow of rounds or support the cognitive development of medical trainees. We describe IDR processes in an academic general medicine inpatient setting and present a rapid cycle quality improvement (QI) project that improved IDR documentation rates in the electronic health record. The project team observed existing daily IDR rounds on two medical inpatient units at the Iowa City VA Medical Center, with three resident teams and maximum census of 42 patients. The major intervention was a redesigned note template, with accompanying resident educational materials. The primary outcome was note completion rates by charge nurses; IDR team member satisfaction and participation, discussion time and balancing metrics (i.e., excess bed days of care, length of stay, and 30-day readmissions) were also assessed. An electronic template and accompanying educational materials designed to parallel the heuristic problem-solving activities of the IDR team led to improvements in IDR note completion rates from 27 to 69 %. Team member satisfaction was high and participation was stable. Discussion time per patient increased modestly, but varied widely between resident teams and by patient. Balancing metrics were unchanged. Unstructured evaluation indicated that documentation times were reduced, and IDR documentation became more timely and useful. IDR notes designed to support the problem-solving processes of an interdisciplinary group improved the timeliness and perceived value of IDR documentation and met regulatory standards. Aligning complex processes and educational and documentation needs during IDR may create an efficient opportunity for sustainable interdisciplinary work and learning in an academic setting.