(Clinical Project): Team Leader: Rozina Shazad Ramji

1. Back ground: Medical records serve many purposes. First and foremost, they document the history of examination, diagnosis and treatment of a patient. This information is vital for all providers involved in a patient’s care and for any subsequent new provider who assumes responsibility for the patient.

2. Significant of the Project: At secondary Hospital it has been identified that significant non compliances in Ambulatory medical records by physician group.

3. Rational for selection of project: In the last two years. It has been observed that ambulatory compliances in the medical Record is not up to the mark. The target of non-compliances is 20% but the actual is above 25% or compliances from 80% to 85% which needs serious attention.

4. Project Mission or Goals: The project aimed to identifying areas of opportunities, to do in -depth analysis of process, designing action plans, execution of plans by implementation of strategies followed by sustainable Plans and strategies.

5. Team Composition: Multidisciplinary team including Administration, Nursing and Security, Led by QPSD team.

6. Data Collection Methodology: Team conducted perito analysis based on file reviewed and identifies areas of opportunities.

7. Use of Quality Improvement Tools: As a tool embedded within Six Sigma methodology DMAIC (Define, Measure, Analyze, Improve, Control) Project Tool was used to examine a process prospectively for possible ways in which failure can occur, and then to redesign the processes so that the new model eliminates the possibility of failure.

8. Significance of Project outcomes: This project enhanced staff (knowledge, attitude, and practice) to prevent from sentinel events. Different strategies were used to overcome issues which include:

ü Develop action plans and monitor timely.

ü Training session has been arranged for physician group.

ü Emphasis in their dept meeting and QICs.

ü Meeting with consultant 1:1 to identify and seek suggestions to improve compliances.

ü Develop user friendly form which was very much appreciated by consultant group.

ü Review Medial Record Audit Tool.

ü Auditor traininghas been done to improve methodology and concept of internal auditor.

ü Flyers pasted for importance and tips of correct documentation.

ü Quality and Patient safety week celebrated to emphasis.


9. Post project sustainability of desired outcomes: Through this project, challenges were successfully identified and addressed. Implemented strategies resulted improvement in the Ambulatory medical record.

10. Sustainability:

• Sustainability via ensure compliances of best practices via audits.

• Continuous educational session.

• Provide quality and Pt safety handbook to all newly induct staff.