1. OB Chart Audits: Improving and Standardizing Prenatal Resident Education and Patient Care Elizabeth Menzel, MD, Kathryn Jacobe, MD, Heidi Vanyo, MD, Julianne Falleroni, DO

2. Who are we?

3. Who are you? Are you currently doing any chart audits? If so, of what types of charts? And for what purpose?

4. Disclosures None

5. Objectives After attending this session, participants will be able to: Assess the opportunities and barriers to OB chart audits in their educational and clinical settings Leave with the tools and knowledge to create and OB chart audit process in their own program Create a list of applications of chart audits in residency education, including but not limited to prenatal care

6. Origins of our Chart Audits Desire to standardize and improve our clinic’s delivery of prenatal care Desire to standardize the content and quality of resident education in prenatal care

7. Desire to standardize and improve our clinic’s delivery of prenatal care Improve handoffs within and out-of clinic Identify and close gaps in patient care Increase level of supervision of patient care Ensure patients receive standardized high-quality, evidence-based care Better manage a complex panel of patients

8. Desire to standardize content and quality of resident education Identify gaps in knowledge, and adjust curriculum to close them Standardize goals of care based on evidence- driven guidelines Educate about PCP responsibility for all aspects of care, even those delegated Teach peer-review and professional practice improvement

9. Task Break into discussion groups

10. Discuss. (2 minutes) Currently Auditing –Discuss current barriers and successes. –Be prepared to share summary points Not Auditing –In what context could you use auditing? –Be prepared to share summary points

11. Share. (2 minutes) Currently Auditing –Share current barriers and successes. Not Auditing –Share in what context could you use auditing?

12. How did we develop our audits? –Found that a sister residency program (UW Verona FMR) was exploring chart audit process, but struggled with legal barriers of documentation –Explored their current materials –Reviewed evidence-based guidelines and made modifications to existing audits

14. How did we develop our audits? –Identified major goal-oriented milestones at which to do audits: 18 w, 28w, 36 w –Adjusted audit structure/questions to correlate with milestone chart audit process

15. How did we develop our audits? –Developed Epic templates and appropriate encounter-type to satisfy being in the chart but not discoverable (per legal department recommendations) We use “clinical info note” –Started auditing Initial audits took “snapshot in time” of entire OB panel. Patients at 36 weeks got 18, 28 and 36 week audits. Patients at 28 weeks got 18 and 28 week audits. Going forward, each patient got an audit at each milestone when achieved

16. What is our current process? –2 week rotating schedule with each faculty (3 of us) taking one milestone and auditing all patients who achieve that milestone during that 2 week session –Faculty completes audit and sends open encounter to residents with list of outstanding tasks to be completed. faculty cc all attendings who have supervised prenatal care since the previous milestone for their education/review, which was requested and appreciated by non-OB faculty.

17. What is our current process? –Residents open separate encounters/addend notes as needed to complete outstanding tasks. Separate from audit encounter –When tasks are completed, residents reply to audit encounter citing encounters where the tasks have been completed then re-send to faculty. –Faculty review documentation of task completion and close encounter if appropriate or re- send/educate about any remaining outstanding tasks.

18. Individual reflection. (2 minutes) Currently auditing –What is something you may take away from our process that you can take to your own program –Write down the first step to incorporate that aspect. Not auditing –What is the biggest barrier to starting audits? –Write down the first step to take to overcome that barrier.

19. Outcomes: Resident Feedback Initial Complaints –Excessive, creates more work –Too much oversight Later Reactions –Improves prenatal care and provider knowledge –Ensures complete care and appropriate documentation –Catches items that may have otherwise been missed –Helps prioritize what needs to be covered in future visits –Keeps all providers involved in a patient’s care up to date when patient care is managed by multiple physicians

20. Outcomes Able to identify overall knowledge gaps for all team members and address those gaps –Example Gaps: genetic screening, nurse education topics, immunization needs, management of post-dates –Example approaches to address gaps: individualized education sessions for nursing, additional didactics/orientation sessions for residents, one on one teaching during staffing Able to identify process failures –Examples: ultrasound result being scanned into system, scheduling of patients, missed immunizations Improved post-dates planning – residents much more aware Helps close loops with referrals, imaging, additional testing that don’t otherwise get flagged as incomplete

21. Where do we go from here? –Residents to perform peer-review audits –Broader context – other chart types (non-OB)

22. Discuss. (4 minutes) How could we improve our current process? What are some other applications of this type of audit process? What are some other benefits of this type of process?

23. Thank you! Elizabeth Menzel, MD elizabeth.menzel@fammed.wisc.edu Katie Jacobe, MD kathryn.jacobe@fammed.wisc.edu Heidi Vanyo, MD