SAFE TRANSFER OF CARE

eMR Quality Improvement Workshop

On Thursday 17 November approximately 40 staff from the NNSW LHD including, Chief Executive, Wayne Jones, Executive staff, Allied Health Managers, Health Information Managers, Junior Medical Officers, Emergency Department Directors and Specialists and Clinical Information Coders attended a workshop in Ballina to workshop electronic medical records (eMR) quality improvement.

On the Agenda:

• Welcome and Introduction (Wayne Jones – CE NNSWLHD)
• Coding of records from the EMR (Matt Long – CIO & Alison Lollback – Health Information Manager)

• Alison coded a pre-prepared/identified eMR record and Matt sought input from those present, especially coders on the issues identified.

• Comprehensive Medical Record (Matt Long – CIO, Dr Tien Khoo – Senior Medical Officer & Dr David Hutton – Executive Director Clinical Governance)

• Discussion of the comprehensive medical record notably: What would it look like? What do we currently have? And What are the key gaps? The attendees were asked to identify constraints / issues with achieving this.

• Demonstration of Patient Journey through eMR (Matt Long – CIO, Dr Rob Davies – Network Director for Emergency Medicine & Dr David Glendining – RMO)

• Using the eMR a walk-through was demonstrated through the patient journey for the record coded earlier. The Doctors were asked to highlight those aspects (root causes) that lead to the issues identified earlier in the discussion of coding and comprehensive medical record.

• Discharge Summaries (Matt Long – CIO & Dr David Glendinning – RMO)

• Dr Glendenning demonstrated how a discharge summary is created and the issues that exist.

• Summary and priorities (Matt Long – CIO)

• The findings were summarised and Matt asked the workshop participants if there was a consensus regarding priority issues and potential solutions.

• Wrap-up and next steps (Vicki Rose – Executive Director Allied Health and Chronic & Primary Care)

Outlined the process to take this project forward and identify the importance of governance and working parties to prioritise solutions and implement change.

Project Proposal

• The project is to be entitled the Safe Transfer of Care
• In scope are all inpatients and emergency departments within NNSWLHD
• Project Overview:

1. Improve the quality of the comprehensive medical record
2. Improve the information collected in the eMR
3. Improve safe clinical handover in and out of hospitals

• Improving workforce satisfaction and sustaining change

Next Steps

• Confirm Governance structure
• Confirm scope with NNSWLHD Executive
• Establish high level schedule
• Establish working party (if needed)
• Identify/name stakeholders

For more information on the next stage of this exciting project please contact project lead Di Goldie, Safe Transfer of Care Project Officer. di.goldie@ncahs.health.nsw.gov.au