Increase the % of Complete On-Time Brief/Full Gynecologic Surgery Operative Notes at
Good Samaritan Hospital from 67% to 95% from August 2013 to January 2014
Issue: TJC requires that a brief operative progress note or a full operative note be available in the
medical record immediately upon completion of surgery. Historical data revealed that only 67% of all
gynecology surgeries performed at Good Samaritan Hospital fulfilled this requirement.
Project Description: Our team goal was to improve the percent of complete on-time brief/full
gynecologic surgery operative notes from 67% to 95% in a 6 month period. We created a key driver
diagram with key drivers and interventions to accomplish this goal. We also created a failure effect mode
analysis to outline the work flow process to target key areas of failure and potential areas for
improvement. Lastly, we created a Pareto chart to discover which clinicians most commonly failed to
meet the operative note requirement. Using PDSA small tests of change and ramping up successful
interventions and spreading those interventions we were able to make sustainable improvements.
Results: Our first set of interventions involved education of clinicians regarding TJC requirements. We
conducted pre/posttest education sessions, circulated email education, made flyers for the OR, and
repeated education efforts at monthly faculty meetings. These education efforts represented a level of
reliability of 1 and increased our baseline on-time completion rate from 67% to 78%. Our team then
worked on an OR reminder process and utilized PDSA cycles and ramps. This evolved instituting a OR
debrief process with PDSA cycles and ramps to refine the process, remind the clinician about the op note,
and communicate to the team who was to be responsible for completing the op note. Lastly, the team
presented blinded Pareto chart information to the individual departmental clinicians focusing on those
who most commonly failed to meet TJC requirements. The team worked with those clinicians to reeducate and examined individual work flow characteristics to improve timely compliance. After these
interventions, the percent of complete on-time gynecologic surgery operative notes increased up to 90%.
Lesson Learned: 1. Culture change is difficult and challenging 2. Getting accurate data is of vital
importance 3. There are a variety of ways to disseminate information and to spread the message usually
multiple ways are necessary 4. Tests of change provide important learning’s even when results are
negative
Submitters: Jack Basil MD Team Leader Departmental Chair (jack_basil@trihealth.com), Mary Anne
Lenk Quality Improvement Specialist, Mindy Traylor Recovery room nurse, Holly Seals, OR nurse, Mary
Pat Gilligan Director Perioperative Services, Corey Clifford DO Resident Physician, Kathy McClish
Clinical Quality Improvement, John Wintersteen IT Specialist.