University of Colorado Hospital

Focus-PDCA
Performance Improvement Team Worksheet
Department!"!#$!%C& D!PA#T"!%T Date'()*+)',
Primary Contact Person#&A% "-#I..!TT! !/tension0+1'''
(F) Find a Process to Improve (name the process, describe the beginning and ending steps in
the process, name the customers served; state why it is important to work on this now).
To examine and improve charting within the emergency department for critical care and code
documentation. ollect information from staff regarding current charting process and develop
improved documentation tool to assist nurses with accurate documentation. This is important for
staff satisfaction as well as effectively and accurately charting patient course through emergency
department and will aide with patient handoff and continuity of care.
-pportunity .tatement
!bility to improve patient care and nurse"staff satisfaction with complex charting narrator with
flexibility and ease of use.
Circle all that apply2
Dimension of Performance2 #imensions of health care performance are those definable,
preferably measurable, attributes of the system that are related to its functioning to maintain,
restore, or improve health care.
$ %fficiency $ &afety
$ &taff &atisfaction $ %ffectiveness
$ 'atient enteredness $ ontinuity
Prioriti3ation2
$ (igh )isk $ (igh *mpact on 'erformance
- (igh +olume $ (igh 'otential for *mprovement
- 'roblem 'rone $ &upports ritical &uccess ,actors
- -ow +olume $ 'atient &afety

-ther........................................................................
.............................................................................
.............................................................................
(O) Organize a team that knows the process:
List Team Members:&/%0s (&ub1ect /atter %xperts) for ode"ritical are 2arrator
-aura /adsen (%pic), )yan /orissette, &andra ,ogel, 3ecky #avis, 3randi &chimpf, and %)
nurses"educators from &outh and 2orth ampuses.
(C) Clarify the current knowledge
What do we know about the process?
*t has been difficult to chart on critical care and coding patients without a dedicated narrator
designed for consistent documentation. 4ith use of other narrators, staff have shown satisfaction
and improved delivery of care.
(U) nderstand sources of !ariation:
Why are we looking at this process? Why is the process not going the way planned?
&taff have verbali5ed a need for a dedicated narrator with all accessibility to document critical
patients without navigating through multiple screens. This will aide in more accurate and timely
charting and billing.
(S) "elect the impro!ement:
!ssist other staff with varied backgrounds to develop ode"ritical are 2arrator by
systematically evaluating current options within %pic charting.
(P) #lan the impro!ement:
4ork with others to have necessary education and resources to effectively use narrator. 'rovide
resources and education opportunities as needed. onsider feedback for changes and updates
in process improvement.
(D) $mplement the impro!ement:
4ith 67o$-ive8 date set, implement ode"ritical are 2arrator. Take feedback and suggestions
to team to evaluate need and benefit of changes.
(C) Check the results:
onduct post implementation survey asking similar 9uestions to evaluate effectiveness
and satisfaction of new charting tool.
(A) %ct to hold the gain:
ontinue to educated and promote ode and ritical are 2arrator and act as resource in its use
and effectiveness. ontinue to change and update narrator based on feedback and suggestions
#epeat PDCA as needed and maintain documentation in your department4