The Science Journal of the American Association for Respiratory Care

2007 OPEN FORUM Abstracts


E. M. Collado-Koman1, R. M. Ford1, T. Morris1, H. French1

Background: We developed a comprehensive WEB based managerial audit tool to improve observation and tracking of RCP documentation. Development was driven by the need to achieve compliance with Joint Commission standards, National Patient Safety Goals, the entry of weaning protocol outcomes, and required elements of the VAP vent bundle. We created a Web entry form and database to capture information at the point of care using mobile PCs devices already in use, which would allow for real time look up of RCP compliance, and allow us to export data for a variety of analysis over any period.

A team was developed to define the data elements to include in the on-line entry form. Once the list was defined, we used a web based data collection (PHP/MySQL) platform to configure the format and content of the program. We used an HTML form in sending data to a MySQL database. Data was then retrieved from MySQL database via a PHP driven download utility. This information was then downloaded as an Excel file. RC supervisors were trained on how to use the on-line tool with the expectation they would complete no less than 4 entries each month. The team leader would enter his/her name, unit name, the name of the therapist whose charting is being audited, date of the audit and the patient medical record number. The team leader would select: Met, Not Met, or Non Applicable as they evaluate items under the categories: Ventilator Charting, Orders, Steer Charting, NPSG, Other RC Documentation/Protocol, and Environment of Care.

In 2006, 379 entries were made in the system on 90 staff members. Entries reflected participation of a 100%of our department team leaders. Data using the tool has been utilized as objective data in department-wide performance improvement projects as well as part of individual performance evaluations. Generated reports have included: RC compliance with VAP recommendations, and RC compliance with NPSG among others.

Conclusion: Screening tools can be developed to effectively quantify documentation compliance and the impact of measures directed at improving the RC practitioner’s performance and documentation. The designing of comprehensive audit tool requires taking into consideration ways in which various interest groups can assess and use it. The use of a web-based managerial accountability tool assists in the tracking and trending of RC practice issues. It also improves communication among managers and practitioners.

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