Best Practices for Procedure Documentation and Tracking Patricia Bouknight, MD Rebecca Beagle, RN, BSN, CHDA, CPHQ Spartanburg Family Medicine Residency Program STFM 2016

Disclosures I have nothing to disclose.

Objectives 1. Discuss challenges and benefits associated with resident-reported procedure logs. 2. Identify and discuss different tactics for acquiring accurate and complete procedure data. 3. List reasons why accurate data is important. 4 Analyze the possible impact of the proposed CAFM consensus statement on the process of procedure tracking and competency evaluation.

About us Dually accredited Spartanburg Medical Center – 540 bed community hospital 2 Practice Sites – Center for Family Medicine – Chesnee Center for Family Medicine (rural) Multiple EMRs Transitioning single EMR RMS-procedure logger

True or False Residents tend to be good loggers of their procedures.

Value – Procedure reporting is necessary for: Accreditation – Web Ads – Program required procedural competencies Evaluation of the program – Education experience Evaluation of the residents – Milestone evaluation (PC-5) – Professionalism Attaining privileges post graduation – Numbers are important!

Our situation Our residents were poor loggers.

Challenges to logging

Tactics Multiple means of logging – Added procedure logger to daily visit screen in MIDAS patient list for inpatient services – Added Resident procedure charge in outpatient EMR – Revised list in Residency Management System Procedure log Extensive Education Quarterly reports for advisor and resident

Inpatient  Added procedure documentation to daily visit documentation screen

Dramatic improvement in documentation of EKG interpretation…… Still required the resident to select and add the procedure….. Procedure and Resident dependent…. Used the inpatient list/MIDAS™ to link location of patient to assist with capture of ICU management

Outpatient clinic…Added Custom list—Resident Procedures. Residents could order procedure.

And then we got a new PD…….

Study – Major joint injections – For one year, from July 2014 through June 2015 – Data was pulled from: Resident-reported procedure logs in New Innovations Resident CPT charge for procedure in Centricity Faculty CPT + GC procedure charges in Centricity

Results 45% of procedures were logged by residents in New Innovations 20% were entered in EMR

Should residents be held accountable for logging as a measure of professionalism? Can EMR offer an alternative to resident reported logs?

Questions for the Group Does anyone do a data pull in addition to or instead of a resident reported log? Do you hold residents accountable for logs?

CAFM proposed guidelines Sets expectations for procedural competency based on training Competency Assessment with PCAT triggered at certain volume target

Our Plan Resident Dashboard in new EMR to track procedures on individual resident and program level Incorporation of procedural skill workshops – Procedure/simulation lab – Periodic competency assessment Include competency assessment in end of rotation evaluation (rotation summary)

Goal=Good Data

Questions/Comments….