title: Aligning complex processes and electronic health record templates: a quality improvement intervention on inpatient interdisciplinary rounds.
abstract: BACKGROUND
  Interdisciplinary rounds (IDR) with documentation have become a standard of care, but the process has been incompletely described in academic general medical settings. Checklists are promoted, yet standardized formats may not reflect the variability and work flow of rounds or support the cognitive development of medical trainees. We describe IDR processes in an academic general medicine inpatient setting and present a rapid cycle quality improvement (QI) project that improved IDR documentation rates in the electronic health record.
  
  
  METHODS
  The project team observed existing daily IDR rounds on two medical inpatient units at the Iowa City VA Medical Center, with three resident teams and maximum census of 42 patients. The major intervention was a redesigned note template, with accompanying resident educational materials. The primary outcome was note completion rates by charge nurses; IDR team member satisfaction and participation, discussion time and balancing metrics (i.e., excess bed days of care, length of stay, and 30-day readmissions) were also assessed.
  
  
  RESULTS
  An electronic template and accompanying educational materials designed to parallel the heuristic problem-solving activities of the IDR team led to improvements in IDR note completion rates from 27 to 69 %. Team member satisfaction was high and participation was stable. Discussion time per patient increased modestly, but varied widely between resident teams and by patient. Balancing metrics were unchanged. Unstructured evaluation indicated that documentation times were reduced, and IDR documentation became more timely and useful.
  
  
  CONCLUSIONS
  IDR notes designed to support the problem-solving processes of an interdisciplinary group improved the timeliness and perceived value of IDR documentation and met regulatory standards. Aligning complex processes and educational and documentation needs during IDR may create an efficient opportunity for sustainable interdisciplinary work and learning in an academic setting.
authors.affiliation: Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System and VA Quality Scholars Fellowship Program, Iowa City, IA, USA. Hilary.mosher@va.gov.|Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA. Hilary.mosher@va.gov.|Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, 52246-2208, Iowa City, IA, USA. Hilary.mosher@va.gov.
authors.forename: Hilary J
authors.initials: HJ
authors.lastname: Mosher
authors.affiliation: Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System and VA Quality Scholars Fellowship Program, Iowa City, IA, USA. daniel.lose@va.gov.|College of Nursing, University of Iowa, Iowa City, IA, USA. daniel.lose@va.gov.
authors.forename: Daniel T
authors.initials: DT
authors.lastname: Lose
authors.affiliation: Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System and VA Quality Scholars Fellowship Program, Iowa City, IA, USA. russell.leslie2@va.gov.
authors.forename: Russell
authors.initials: R
authors.lastname: Leslie
authors.affiliation: Department of Industrial Engineering, University of Iowa College of Engineering, Iowa City, IA, USA. priyadarshini-pennathur@uiowa.edu.
authors.forename: Priyadarshini
authors.initials: P
authors.lastname: Pennathur
authors.affiliation: Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System and VA Quality Scholars Fellowship Program, Iowa City, IA, USA. peter.kaboli@va.gov.|Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA. peter.kaboli@va.gov.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Kaboli
mesh_terms: D000368:Aged; D004282:Documentation; D057286:Electronic Health Records / Q000458:organization & administration*; D005260:Female; D006801:Humans; D007297:Inpatients; D033183:Interdisciplinary Communication; D007407:Interviews as Topic; D007484:Iowa; D008297:Male; D008875:Middle Aged; D036301:Qualitative Research; D058996:Quality Improvement; D056164:Teaching Rounds / Q000592:standards*