Overview
UC Davis Health, based in Sacramento, California, knew that implementing quality improvement measures required operational and clinical analytics to guide process development and care redesign efforts. This case study explains how the health system addressed clinical documentation challenges through better data, education, communication, and collaboration across disciplines and delivered better patient outcomes.
The Challenges
One of the key challenges UC Davis Health faced was capturing and documenting New York Heart Association (NYHA) classifications in preoperative notes for emergent surgeries. The clinical team was struggling to re-evaluate and update clinical severity using NYHA if a patient's condition worsened within the required timeframe set by The Society of Thoracic Surgeons. Previous arrhythmias were not consistently documented in preoperative appointment documentation, especially for first-time patients who were already admitted. The administration of preoperative beta blockers for admitted patients was inconsistent, and substance abuse counseling was not consistently ordered or available.
Other challenges included incorrect clinical status selections, variations in documentation formats for noting complications, incomplete SmartPhrase documentation for procedures, inconsistent formats for discharge summaries, inconsistent ordering of cardiac referrals, discrepancies in blood administration counts in discharge summaries compared to EPIC, and overall long length of stay, especially in the ICU and OR, and extended OR times.
Actions Taken Using the STS National Database
To start, nurse practitioners, physician assistants, and scribes worked together to ensure NYHA was added to each preoperative note, provide education on compliance, and capture the highest applicable NYHA level. For previous arrhythmias, they added information to outpatient office visit summaries and preoperative progress notes and implemented measures to ensure the full history was documented. For preoperative beta blockers, they assessed orders, added metoprolol to the order set, and created a system to cross-check medication administration.
A heightened focus was placed on working with the STS National Database team to improve the hospital’s data submission process. SmartPhrases were reviewed and compared to the STS National Database to make sure the information was complete and accurate. Discharge summaries were evaluated and updated, using the same SmartPhrase across all CT staff. Cardiac referral orders were added to discharge summaries to improve consistency.
For discharge medications, the hospital updated summaries with a drop-down for contraindications and improved documentation. Blood administration discrepancies were addressed by removing the documentation and extracting correct data from EPIC. The overall length of stay was broken down by area and compared to the STS national benchmarks, leading to discussions with staff in each department on process improvements.
For OR times, CPB start and stop dates and times were added to reports, breaking down each part of the OR process, and educating surgeons on intraoperative times.
Substance abuse counseling challenges were addressed through meetings and discussions with social workers, case managers, and the substance use navigator (SUN) team. A standardized packet for patients was developed, and education on the importance of early referrals was provided to cardiothoracic surgery staff. Inaccurate clinical selections were corrected in real-time through training, asking questions and regularly reviewing issues with residents and surgeons.
Results
Documentation of complications was improved through more accurate, comprehensive use of data, education, reassessment, and presentations to the integrated care team. The hospital achieved continued improvements in the preoperative beta blocker project, better accuracy in clinical status choices, improvements in discharged medications, enhanced discharge summary quality, and accurate complications reporting. Blood administration documentation saw increased consistency, a reduction in OR times, and a decrease in the overall length of stay.
Moreover, staff gained a greater appreciation for the consistent use of STS Adult Cardiac Training Manual, reaching out to organizations like the STS for clarification, establishing good communication and relationships with surgeons, and providing real-time feedback on positive and negative outcomes.
Ultimately these improvements help make the data managers’ job more efficient and effective. It takes them less time to follow up with surgeons about missing documentation and delivers a more accurate reflection of the site's performance.