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    An outpatient performance improvement project: A baseline assessment of adherence to pain reassessment standards

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    Author
    Ross, A.
    Feider, L.
    Nahm, E.-S.
    Date
    2017
    Journal
    Military Medicine
    Publisher
    Association of Military Surgeons of the US
    Type
    Article
    
    Metadata
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    See at
    https://doi.org/10.7205/MILMED-D-16-00104
    Abstract
    Background: 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. Methods: 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). Results: 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. Discussion: 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.
    Keyword
    ambulatory care facilities
    ketorolac
    ketolorac tromethamine
    military personnel
    outpatients
    pain
    pain measurement
    primary health care
    electronic medical records
    performance improvement
    workflow
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    Identifier to cite or link to this item
    https://www.scopus.com/inward/record.uri?eid=2-s2.0-85018794181&doi=10.7205%2fMILMED-D-16-00104&partnerID=40&md5=f6cd2e4ae8dba6b266c40e6d5d1ff5a7; http://hdl.handle.net/10713/11150
    ae974a485f413a2113503eed53cd6c53
    10.7205/MILMED-D-16-00104
    Scopus Count
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    UMB Open Access Articles 2017

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