Putting a stamp on quality improvement through documentation

Robyn Vincent1, Jordan Madigan2

1Allied Health Professional (Occupational Therapist), Community based support, Transition Care Program, Murray Mallee Community Health Service, Riverland Mallee Coorong Region, CHSALHN, PO Box 346, Murray Bridge  SA  5253, email: robyn.vincent@sa.gov.au
2Physiotherapist, Transition Care Program, Murray Mallee Community Health Service, Riverland Mallee Coorong Region, CHSALHN, PO Box 346, Murray Bridge  SA  5253

Background

The Transition Care Program (TCP) multidisciplinary team (MDT) services the Murray Mallee area of CHSALHN in South Australia.  A review of current processes against the National TCP Quality Standards of Care demonstrated insufficient evidence in complying with some sections of Standard 2: Multidisciplinary Approach. The existing weekly MDT meeting was minuted on a proforma and made available to attendees. There was no evidence in client medical records of MDT discussion, either around goal achievement or of regular meetings.

Methods

All MDT team members participated in a 4-month trial of an ink-stamped proforma, to facilitate the agenda of meetings and give structure for documentation in client medical records. The stamp included prompts to focus discussion around client centred goals, summary of achievements/highlights, agreed actions and attendance.

Results

A clinical audit of medical records was conducted post the introduction of the stamp and a questionnaire was conducted with the MDT. The audit showed the stamp provided evidence in the medical record of multidisciplinary involvement.   Other key outcomes included: improved meeting structure, decreased extraneous discussion resulting in greater time efficiency.

Discussion

This was a low cost strategy providing evidence of compliance with National TCP Standards. The structure of the meeting increased focus on client goal achievement, with greater engagement of clinicians in documenting client discussion, whilst meeting time constraints. Recommendations include continued use of the stamp; making it more generic and available across CHSALHN TCP programs; and adding Estimated Discharge Date to provide further evidence for the standards.

Biography

Robyn Vincent has worked in the Transition Care team at Murray Mallee Community Health Service for 6 years in the role of Allied Health Clinician Community Based Support.  She completed her Occupational Therapy studies with Honours in 2006. Her previous roles include rehabilitation programs and research therapy at the Repatriation General Hospital and some time in a private practice.Robyn is a strong advocate of providing equitable services for rural communities and has a strong focus on quality improvement and program development.