UMass Memorial Health System Suicide Steering Committee identified three focused areas for continuous improvement for patients at risk for suicide: incomplete evidence-based suicide risk assessments, inadequate documentation of observation levels, and gaps in environmental checklist documentation. The team implemented enhancements through our EPIC electronic medical system to increase compliance and improve the quality of care provided to at-risk patients. By leveraging the functionalities of EPIC, we streamlined documentation processes and reinforced care standards across our healthcare continuum. These enhancements facilitated an impressive 35% increase in compliance with documentation standards and elevated the overall quality care delivered to our patients.
Problem: After the initial launch of a system-wide initiative to improve the care of patients at risk for suicide in 2018, ongoing evaluation by the UMMH Suicide Steering Committee identified three focused workflows requiring improvement: incomplete evidence-based suicide risk assessments, inadequate documentation of observation levels, and gaps in environmental checklist documentation.
Measurement: To effectively visualize our progress and outcomes, we utilized a wide range of measurement tools including bar graphs, control charts, dual-axis charts, dashboards, and data extracted from within EPIC to analyze through the tableau platform.
Analysis: Our analysis process was comprehensive involving evaluating pre and post data. Comparative analysis of the presence of an evidenced-based suicide assessment, completion of observation checks, and environmental screens according to policy. Reviews were conducted across various service lines to ensure a standardized approach and compliance.
Implementation: Throughout the implementation process, we focused on enhancing documentation of the CSSRS-RA, combined observation and environmental checklist documentation into one flowsheet, optimized suicide risk mitigation orders, implemented BPAs, and leveraged Care Everywhere and EpiCare Link. We closely collaborated with informatics colleagues to assist with any obstacles along the way.
Results/Discussion: Our efforts resulted in an impressive 35% increase in compliance with our documentation across all three focused workflows. To ensure the sustainability of our implementations, we conduct regular system meetings to review data and discuss opportunities. This commitment to monitoring and refinement highlights our dedication to delivering quality patient care.
