Improving medical record completeness at Wallaga University Referral Hospital: a multidimensional quality improvement project.

BACKGROUND: Appropriately documented medical records enhance coordination, patient outcomes and clinical research. OBJECTIVE: The aim of this project was to improve Wallaga University Referral Hospital's (WURH) medical record completeness rate from 53% to 80% from 1 January 2023 to 31 August 2023. METHODS: A hospital-based interventional study was conducted at WURH. The Plan-Do-Study-Act cycle was used to test change ideas. A fishbone diagram and a driver diagram were used to identify root causes and address them. Key interventions consisted of supportive supervision, developing and distributing standardised formats, orientation for staff, establishing a chart audit team and assigning data owners. RESULT: On the completion of the project, the overall implementation of inpatient medical record completeness increased from 53% to 82%. This improvement varies from department-to-department. It increased from 51% to 79%, 53% to 79%, 46% to 81% and 64% to 91% in the departments of internal medicine, paediatrics, obstetrics and gynaecology and surgery, respectively. The project brought improvements in the completeness of physician notes (84% to 100%), physician order sheet (54% to 84%), nursing care plan (26% to 69%), admission sheet (76% to 98%), discharge summary (94% to 98%), progress note (38% to 91%), medication administration (80% to 100%), appropriate attachment of documents (78% to 93%) and documentation of vital signs (50% to 100%). CONCLUSION AND RECOMMENDATION: The rate of medical record completeness was significantly improved in the study area. This was achieved through the application of multidimensional change ideas related to health professionals, supplies, health management information systems and leadership. However, in some of the parameters, the national targets were not met. Therefore, we recommend providing regular technical updates, conducting frequent chart audits and providing supportive supervision for the enhancement of medical record completeness. It is also advisable for the hospital management to work on its sustainability.

Pain-free hospital implementation: a multidimensional intervention to improve pain management at Wallaga University Referral Hospital, Nekemte, Ethiopia.

OBJECTIVE: This quality improvement project is aimed to increase pain free hospital implementation from 21.7 to 80% at Wallaga University Referral Hospital (WURH) from January 1, 2023 to June 30, 2023. METHODS: Hospital based interventional study was conducted at WURH. The Plan- Do-Study-Act (PDSA) cycle was used to test change ideas. A fishbone diagram and a driver diagram were used to identify root causes and address them. Major interventions included training of health professionals, initiation of pain as fifth vital sign, policy and protocol development, and conducting regular supportive supervision. RESULTS: Upon completion of the project, overall pain-free hospital implementation increased from baseline 21.7-88.7%. Implementation of pain as 5th the vital sign was increased from 15.4 to 92.3%. Regular audits of pain assessment and management increased from 27.3 to 81.8%. Two standardized treatment protocols or chronic and acute pains were developed from baseline zero. A focal person for Pain-free hospital implementation was assigned. More than 85% of healthcare providers were trained in pain assessment and management. CONCLUSION: Compliance with pain-free hospital implementations was significantly improved in the study area. This was achieved through the application of multidimensional change ideas related to health professionals, standardized guidelines and protocols, supplies, and leadership. Therefore, we recommend providing regular technical updates & conducting a frequent clinical audit on pain management.