Abstract TP363: Action Plan Improves Order Set Use Compliance
Background: It is known that order sets improve clinical performance and regulatory compliance by establishing standards of care and advancing the practice of evidence-based medicine, however, compliance in order set use can be a challenge. We are a five-hospital system operating as one with 1,500 stroke patient admissions per year. During our initial Primary Stroke Center certification review in May 2009, we received a Requirement for Improvement (RFI) citation because the order sets were not used consistently. The purpose is to describe actions taken to improve and maintain compliance of admission order set use.
Methods: Stroke program leaders met to develop an action plan to address the order set RFI. A baseline audit of order set use revealed a 14.9% compliance rate. This information was reported to the system President and Chief Nursing Officer (CNO) at each location. The President met with the Medical Executive Committee who made the decision to make order sets mandatory, effective immediately. A follow-up article summarizing the survey results, metrics and action plan was published in the electronic physician newsletter. The Stroke Medical Director drafted a letter to the medical staff. Educational meetings with the Hospitalists were held and the CNOs implemented a stop-the-line plan. Compliance was monitored monthly. Physicians who did not comply received a letter. After three letters, the physician is required to report to the Quality Peer Review Committee.
Conclusion: This action plan was an effective means to improve and maintain order set use compliance resulting in increased compliance with performance measures. We are in the process of phasing in computerized physician order entry. Interactive forms (I-forms) have been developed with functionality to aide in meeting compliance, quality and safety measures. It is imperative that we continue to monitor and address I-form order set compliance monthly.
- © 2012 by American Heart Association, Inc.