Ross Angela, Feider Laura, Nahm Eun-Shim, Staggers Nancy
UTHealth School of Biomedical Informatics, University of Texas Health Science Center at Houston, 7000 Fannin, Suite 690, Houston, TX 77030.
Department of Nursing Science, Army Medical Department Center and School, Fort Sam Houston, Joint Base San Antonio, TX 78234.
Mil Med. 2017 May;182(5):e1688-e1695. doi: 10.7205/MILMED-D-16-00104.
This performance improvement (PI) project was conducted to recommend improvements for pain reassessment workflow and policies at a large military primary care clinic. The Joint Commission survey identified inconsistent pain reassessment practices at the facility in 2012. A review of the literature reveals that pain reassessment procedures can be affected by unclear organizational policies, poorly designed documentation procedures, and redundant or inefficient workflow practices. This PI project was designed to assess pain reassessment compliance rates, associated documentation, and clinic workflow, and to identify opportunities for improvement.
Pain reassessment compliance was evaluated using an Electronic Medical Record (EMR) query for patients treated between February 1 and May 30, 2013, who received Toradol at a large military outpatient clinic (n = 151). In addition, observations of clinic workflow were conducted using tracer methodology as recommended by The Joint Commission to track a convenience sample of 12 patients moving through clinic care processes. Pain reassessment documentation and workflow procedures were then evaluated using the Situation Awareness (SA) framework, which is an approach used to evaluate operational implications of factors affecting staff decisions and performance (e.g., stress and workload, interface design, automation, complexity of workflow, staff abilities and training, goals and expectations).
The EMR review revealed compliance rates greater than 90% for all pain reassessment requirements with the exception of the maximum 30-minute interval between initial and follow-up pain assessment required by clinic policy, which had a compliance rate of 38%. Pain reassessments were documented to occur at a mean time of 48.25 minutes after initial assessment. During the tracer, none of the 12 patient encounters was fully compliant with clinic policies. An analysis of clinic workflow using the SA framework revealed that the SA of clinic staff was impacted by a lack of standardized procedures and heavy reliance on staff memory.
Recommendations for improvement included possible extension of the 30-minute time requirement, development of a template for pain reassessment documentation in the EMR, standardizing hand off and admission/discharge processes, and designing an electronic or manual dashboard to indicate pain reassessment times. Future PI projects in other military clinics would benefit from use of the SA perspective to review clinic policies, EMR documentation, and workflow analysis. Further analysis will be needed to evaluate the impact of these improvements.
本绩效改进（PI）项目旨在为一家大型军事初级保健诊所的疼痛重新评估工作流程和政策提出改进建议。联合委员会的调查发现，该机构在2012年的疼痛重新评估实践不一致。文献回顾显示，疼痛重新评估程序可能受到组织政策不明确、文档程序设计不佳以及工作流程冗余或低效的影响。本PI项目旨在评估疼痛重新评估的合规率、相关文档和诊所工作流程，并确定改进机会。
通过电子病历（EMR）查询，对2013年2月1日至5月30日在一家大型军事门诊诊所接受托拉朵治疗的患者（n = 151）进行疼痛重新评估合规性评估。此外，按照联合委员会的建议，采用追踪方法对诊所工作流程进行观察，以追踪12名患者在诊所护理过程中的便利样本。然后使用态势感知（SA）框架评估疼痛重新评估文档和工作流程程序，该框架是一种用于评估影响员工决策和绩效的因素（如压力和工作量、界面设计、自动化、工作流程复杂性、员工能力和培训、目标和期望）的操作影响的方法。
EMR审查显示，除诊所政策要求的初始和后续疼痛评估之间最长30分钟的间隔外，所有疼痛重新评估要求的合规率均超过90%，该间隔的合规率为38%。疼痛重新评估记录显示，初始评估后平均48.25分钟进行。在追踪过程中，12次患者就诊均未完全符合诊所政策。使用SA框架对诊所工作流程进行分析发现，诊所工作人员的态势感知受到缺乏标准化程序和严重依赖员工记忆的影响。
改进建议包括可能延长30分钟的时间要求，开发EMR中疼痛重新评估文档的模板，规范交接和入院/出院流程，以及设计电子或手动仪表板以显示疼痛重新评估时间。其他军事诊所未来的PI项目将受益于使用SA视角来审查诊所政策、EMR文档和工作流程分析。需要进一步分析以评估这些改进的影响。
