OBJECTIVE: This study aimed to improve the electronic documentation of outpatient antenatal care from 18% (58/325) to 85% in the EMR by J9 staff from November 2020 to September 2021. The experiences that this quality improvement project team encountered could help others improve electronic data collection as well as the transition from paper to electronic documentation within a burgeoning health care system.
METHODS: A continuous quality improvement strategy was undertaken as the best approach to improve the EMR data collection at Hôpital Universitaire de Mirebalais. The team used several continuous quality improvement tools to conduct this project: (1) a root cause analysis using Ishikawa and Pareto diagrams, (2) baseline evaluation measurements, and (3) Plan-Do-Study-Act improvement cycles to document incremental changes and the results of each change.
RESULTS: At the beginning of the quality improvement project in November 2020, the baseline data entry for antenatal visits was 18% (58/325). Ten months of improvement strategies resulted in an average of 89% (272/304) of antenatal visits documented in the EMR at point of care every month.
CONCLUSIONS: The experiences that this quality improvement project team encountered can contribute to the transition from paper to electronic documentation within burgeoning health care systems. Essential to success was having a strong and dedicated nursing leadership to transition from paper to electronic data and motivated nursing staff to perform data collection to improve the quality of data and thus, the reports on patient outcomes. Engaging the nursing team closely in the design and implementation of EMR and quality improvement processes ensures long-term success while centering nurses as key change agents in patient care systems.
目的:本研究旨在从2020年11月至2021年9月,J9员工在EMR中将门诊产前护理的电子文档从18%(58/325)提高到85%。这个质量改进项目团队遇到的经验可以帮助其他人改进电子数据收集,以及在新兴的医疗保健系统中从纸质文件向电子文件的过渡。
方法:采取持续质量改进策略作为改进Mirebalais大学EMR数据收集的最佳方法。该团队使用了几种持续质量改进工具来进行此项目:(1)使用Ishikawa和Pareto图进行根本原因分析,(2)基线评价测量,和(3)计划-做-研究-行动改进周期,以记录增量变化和每个变化的结果。
结果:在2020年11月质量改进项目开始时,产前就诊的基线数据输入为18%(58/325)。10个月的改进策略导致EMR在每个月的护理点记录的平均89%(272/304)的产前检查。
结论:这个质量改进项目团队遇到的经验可以有助于在新兴的医疗保健系统中从纸质文档过渡到电子文档。成功的关键是拥有强大而敬业的护理领导,从纸质数据过渡到电子数据,并激励护理人员进行数据收集,以提高数据质量,因此,关于患者预后的报告。让护理团队密切参与EMR和质量改进流程的设计和实施,确保长期成功,同时将护士作为患者护理系统中的关键变革推动者。