Best Practice
Physician Compliance through Education and Documentation/Reminder Tools
Hospital:
St. Vincent Health Center, Erie, PA (Stroke module)
 410 beds; 40 stroke/month
Key
Stakeholder
Overview:
Stroke Outcome Care Manager (OCM)
As the hospital worked toward stroke certification a number of
initiatives were implemented to facilitate JC and GWTG
compliance. Compliance with quality measures was not at or
above the hospitals’ goal.
 A quality initiative was implemented to insure
overall compliance and documentation with all quality
measures.
 Focus was on physician education and
documentation
Physicians are informed of new guidelines or concerns about our
stroke patient care in the physicians’ newsletter.
St. Vincent’s process for revising any process or protocol is
always a team effort. The ultimate goal is to provide the tools and
assistance to the physicians and nurses that will improve patient
care; while at the same time providing the professional team with
the recognition that they were already doing a great job.
In order to insure success in meeting the hospital’s compliance
goal some process changes and documentation reminder tools
were implemented.
Implemented to meet overall goals:
 Hospital-wide stroke education effort
 Physician “tip” sheet
 Physician communication form
 Just-in-time” education interventions
 Hospital-wide dysphagia screens
 Revised
order
sets
(necessary
documentation of care)
for
improved
Key to this hospital’s success is a sense of mutual respect and a
culture that promotes physician approachability. For each
initiative the relevant units were consulted for input and also to
facilitate a sense of ownership.
Process /
Timeline
Revised order set took about 4-5 months.
Input was obtained from individual units/departments to obtain
reaction to revised tools and changed processes; “how to make it
easier for them.” Interdisciplinary team’s input was limited to just
those parts that apply to them (nursing, hospitalists, ED,
neurologists, ST, etc.). Departmental input led to improved
understanding and likelihood of use.
Physician “tip”sheet”: (How it Works)
Importance of Recognition
Each day the chart is checked, the OCM brings the Physician
reminder form to the front of the progress note section and
updates the form if necessary.
For example: a physician could have ordered the physical
therapy consult because it was checked off as not having been
ordered. The OCM would write, “Done—thanks! ” on the
reminder form where she had previously checked the “PT
consult” box.
The physician knows that it was ordered and that his prompt
response was appreciated.
“Just in Time” Physician Education:(How it Works)
“Just in time” education takes place when an OCM determines
that a guideline must be addressed for a particular patient. “Just
in Time” education can be done via direct communication and or
via a data sheet or physician reminder sheet.
“Just in time” education is initiated when we address a physician
(or nurse) on the unit about a specific patient.
For example: the OCM may approach physicians while they are
present on the unit regarding DVT prophylaxis. A gentle
reminder that DVT prophylaxis must be ordered for those patients
who are not ambulating by themselves. Information is given
regarding the patients ambulatory status. Treatment is ordered
by the MD or if the patient is ambulating independently, the
physician is then asked to document that in his or her notes.
In addition to the attending physicians the OCM interacts with
the physician hospitalists. If there is any aspect of patient care
that is of a concern it can be discussed immediately with the
hospitalists, they can be directly approached or paged if
necessary.
A key success factor in our compliance effort is our excellent
team communication which includes physicians and all patient
care disciplines such as social work/discharge planning, physical
therapy, etc.
Physician communication form
A gold-colored form is placed on all patient charts under the
“physician progress notes” section. It has a place for the
date/time, a line for the physician’s name for whom the
communication is being left, a block for writing your message and
a line for your name, pager, etc. There is a block immediately
next to this for the physician to respond to the initial
communication. This form can be used by any member of the
interdisciplinary team. At times, this form may be used in
addition to the physician reminder sheet. This is a hospital-wide
form that was not related to any of our evidence based practices,
but is still utilized for EBP purposes if needed.
Implementation: Order sets not mandatory
 100% usage for TIA
 75% usage for non hemorrhagic stroke: she knows to
review these particular charts
Education:
There are multiple efforts to educate and communicate any
revised procedures/protocols, including:
 House-wide education, with more information to stroke
units
 Interdisciplinary team takes information back to own units
 New indicators communicated via education and inservice
opportunities,
team
meetings,
general/physician/nursing newsletters
 Letters to referring physicians describing changes with inperson follow-up
 Distribution of tip sheets (dysphagia screens)
 New nursing orientation: stroke lectures include exact
replicas of teaching tools and care plans (preceptors
follow-up
o Stroke floor new nurses care for 2 stroke patients
during orientation
o Non-stroke nurses better prepared to recognize
and care for in-patient strokes (provided with
laminated card)
Compliance
Communication
Various methods are employed, including:
 Reminder sheets to request follow-through on items
forgotten or not documented
 “Just-in-time” education: catch nurse/physician at time of
concern; address it while fresh in their mind
Impact:
 The bright green physician reminder sheets and just in
time education have been successful quality improvement
initiatives. The implementation of those two programs has
resulted in improvement in patient care and adherence to
quality measure goals.
Example: Hospitalists’ have approached the Stroke Outcomes
Advice:
Manager prior to leaving the unit stating, “I saw that Mrs. X
needed DVT prophylaxis and I ordered Lovenox.” Many times
the physicians will immediately “flip” the chart open to the
physician reminder sheet to determine what needs to be
addressed for the patient.
 St. Vincent’s is currently at or above all their quality
measure goals, and continues to strive to be defect-free.
 There is an enthusiastic acceptance of order sets along
with improved awareness of overall dysphagia screening
protocols.
 90% compliance with dysphagia measure within one
month
 ST receiving fewer inappropriate non-stroke patient
referrals
The initiatives paid off with improved compliance, particularly for
dysphagia screens
 Team work is necessary for any best practice to succeed
 All potential care team members must be educated so
they understand how to use a new tool or form and what the
expectation is for that tool and the patient’s outcome.
 A defined plan for communication must be established.
 Skilled non threatening methods of verbal communication
are essential when educating on quality measures.
St. Vincent’s is fortunate to have physicians that can be
approached directly for any concerns about the patient care and
the potential plan for the patient’s discharge.