Quality improvement in practice: The importance of creating effective documentation tools

Background: Standardization and accountability are key aspects of modern quality improvement (QI). However, research points to tradeoffs of standardizing practice and difficulties in holding organizations and providers accountable for performance. Accountability is reliant on the practice of documentation. Documentation is an ongoing task with physical, cognitive, and social components and occupies much time and attention of providers. Cumulatively, paperwork imposes a burden of “invisible work”-work that is effortful and time consuming but not given much formal consideration- that has a large effect on work routines and consequently, ability to provide good patient care. In order to optimize QI initiatives in hospitals, this qualitative study examines the effectiveness of QI documentation tools at the point of care delivery. I focus on QI initiatives in obstetrical care, including programs to address emergency events (obstetric hemorrhage) and patient satisfaction (nurse teaching plans). Obstetrics is an area of medicine recently targeted for under-performance.

Methods: Ethnographic observations of the implementation and ongoing use of two QI initiatives took place in the labor & delivery unit of a Southern California hospital over the course of 15 months. Semi-structured interviews were conducted with nurses, managers, physicians, and staff members from interdisciplinary units involved in the initiatives. A set of rigorous coding steps outlined by Grounded Theory was used to analyze the data.

Results: Achieving qualitative improvements through QI initiatives is much harder than demonstrating improved performance on paper. Documentation tools that are most effective are those that draw on (rather than replace) the expertise of providers; stimulate communication and connection between providers or providers and patients; are adaptable to alterations in the work system that change the execution of the tools; are constantly re-examined and altered through collective reflective practices, such as debriefs; and achieve accountability without imposing an excess of cumbersome paperwork.