Team Documentation Implementation Checklistframework for a Quality Improvement Or MOC Part

Team documentation implementation checklistFramework for a quality improvement or MOC Part IV activity

Assess
Identify opportunities for improvement.
In reviewing this toolkit, did you see any strategies that are not currently being used in your practice that may help patient visits run more efficiently and preserve the physician’s focus on the patient, not the computer?
Obtain baseline data to understand the current state.
Use this module’s proposed metrics to measure an indicator that is important to the practice, such as an outcome or satisfaction measure.
Improve
Create a change team.
Select a high-level champion and create a multi-disciplinary team that includes decision makers and staff who will be involved in the new process.
Decide who will help with documentation.
The type of documentation assistant (e.g., medical assistant, nurse, pre-med student, etc.) will determine the scope of their work.
Determine the model: Clerical Documentation Assistant (CDA) or Advanced Team Based Care.
Will the documentation assistant only aid with documenting the patient visit, or will they be clinically trained and have responsibilities beyond documenting the visit note?
Start with a pilot.
Choose one or two physicians in the practice who can start to use the team documentation model first.
Select the pilot personnel based on commitment.
Choose staff who will be eager to learn new responsibilities and help shape the new process.
Define your workflow.
Identify who will be responsible for which elements of the patient visit, and how the visit will take shape.
Start small.
Use the new process for only a subset of patients—e.g., every other patient—during the first week. This will allow staff to develop proficiency without falling behind schedule. Continue to roll out as the team becomes more comfortable.
Meet weekly.
Training and feedback should be consistent throughout the implementation process. Use regularly scheduled meetings to provide feedback and keep the team aligned.
Reassess and reinvigorate
Measure your success using the pre-determined metrics.
Use results obtained from the chosen metrics to identify what is working well and where improvement efforts should be focused. If participating in an MOC activity or a quality improvement effort, multiple improvement cycles may be undertaken.
Celebrate and reinforce successes to keep the team energized and committed.
Make the process fun and engage front-line staff in all phases of the improvement effort.

Source: AMA. Practice transformation series: team documentation. 2015.

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