Beacon Hospital Beacon Court, Bracken Rd, Sandyford Business Park, Sandyford, D18 AK68 Dublin, Ireland.
UCD Centre for Interdisciplinary Research, Education & Innovation in Health Systems, School of Nursing, Midwifery & Health Systems UCD Health Sciences Centre, D04 V1W8 Dublin, Ireland.
Int J Environ Res Public Health. 2021 Nov 21;18(22):12217. doi: 10.3390/ijerph182212217.
Clinical documentation is a key safety and quality risk, particularly at transitions of care where there is a higher risk of information being miscommunicated or lost. A surgical operation note (ON) is an essential medicolegal document to ensure continuity of patient care between the surgical operating team and other colleagues, which should be completed immediately following surgery. Incomplete operating surgeon documentation of the ON, in a legible and timely manner, impacts the quality of information available to nurses to deliver post-operative care. In the project site, a private hospital in Dublin, Ireland, the accuracy of completion of the ON across all surgical specialties was 20%. This project sought to improve the accuracy, legibility, and completeness of the ON in the Operating Room. A multidisciplinary team of staff utilised the Lean Six Sigma (LSS) methodology, specifically the Define/Measure/Analyse/Design/Verify (DMADV) framework, to design a new digital process application for documenting the ON. Post-introduction of the new design, 100% of the ONs were completed digitally with a corresponding cost saving of EUR 10,000 annually. The time to complete the ON was reduced by 30% due to the designed digital platform and mandatory fields, ensuring 100% of the document is legible. As a result, this project significantly improved the quality and timely production of the ON within a digital solution. The success of the newly designed ON process demonstrates the effectiveness of the DMADV in establishing a co-designed, value-adding process for post-operative surgical notes.
临床文件是一个关键的安全和质量风险，特别是在护理交接时，信息更容易被错误传达或丢失。手术操作记录（ON）是确保手术团队和其他同事之间患者护理连续性的重要医疗法律文件，应在手术后立即完成。手术医生未能及时以清晰、完整的方式完成手术操作记录会影响护士提供术后护理的信息质量。在都柏林的一家私立医院的项目现场，所有外科专业的 ON 完成准确性为 20%。该项目旨在提高手术室 ON 的准确性、可读性和完整性。一个由多学科工作人员组成的团队利用精益六西格玛（LSS）方法，特别是定义/测量/分析/设计/验证（DMADV）框架，为 ON 文档设计了一个新的数字化流程应用程序。引入新设计后，100%的 ON 都以数字方式完成，每年节省成本 10,000 欧元。由于设计的数字平台和必填字段，完成 ON 的时间缩短了 30%，确保了 100%的文件都是清晰可读的。因此，该项目通过数字化解决方案显著提高了 ON 的质量和及时生成。新设计的 ON 流程的成功证明了 DMADV 在为术后手术记录建立共同设计、增值流程方面的有效性。
