O3202: Increasing the Percentage of Problem Lists Marked as Reviewed at Discharge by the Pediatric Hospital Medicine Service

Purpose/Objectives: Problem lists are a key factor in ensuring patient safety, accuracy of documentation, and accurate communication amongst providers within the electronic health record (EHR). The problem list is utilized for research, artificial intelligence tools, and reimbursement. Using quality improvement methodology, the goal of the authors was to increase the amount of problem lists reviewed at discharge at a free-standing children’s hospital. The SMART Aim is to increase the percentage of problem lists marked as reviewed at discharge by the pediatric hospital medicine (PHM) service from 26% to 75% in 9 months. As a secondary measure, the authors also monitored the percentage of problem lists updated at discharge by the PHM service.

Design/Methods: Weekly data on all patients discharged from the PHM service was collected. At baseline, over an 8-month period, the problem list was marked as reviewed at discharge in 26% of patient charts and updated at discharge in 44% of patient charts. The process measures of marking the problem list as reviewed and updating the problem list at discharge (both within 24 hours of discharge) were recorded on control charts. Key drivers include standardization of discharge process, optimization of EHR documentation, resident engagement, and attending engagement.

Initial PDSA cycles focused on incorporating the problem list into the standard workflow of residents and attendings. A standardized documentation phrase was created to auto populate the hospital problem list into the discharge summary. In addition, a prompt instructing the discharge summary writer to update the problem list, mark it as reviewed, and refresh the discharge summary, was incorporated into the template.

This standardized documentation phrase intervention was first introduced to one PHM rounding team, then to all four PHM rounding teams, and subsequently added into the discharge summary template as part of a PDSA ramp. Additional interventions included educational sessions, posting of control charts, reporting comparisons of individual provider statistics, and adding prompts to attending attestation templates. Formal feedback was collected from the clinical documentation improvement (CDI) team to ensure appropriate documentation, which was maintained throughout the project.

Results: Following initial PDSA cycles and shifts, the mean line for marking the problem list as reviewed at discharged shifted from 26% to 71% (Figure 1). For updating the problem list at discharge, the mean line shifted from 44% to 77% (Figure 2).

Conclusion/Discussion: Implementation of EHR tools can optimize documentation and standardize workflow around the problem list. Incorporating reminders into discharge summary templates is an effective tool to improve the percentage of problem lists marked as reviewed and updated at discharge. Next steps include expanding prompts in attending templates and evaluating accuracy of the problem list.