Proper Use of Documentation the Improvement of Healthcare Quality - Essay Example

Proper Use of Documentation in Improvement of Healthcare Quality

The documentation process refers to the keeping of both patient and organizational records for future reference. More often than not, the documentation process, as done by the nurses creates a platform through which research can be conducted and thus improve the places with malfunction. Proper use of documentation is also a crucial factor in patient care as it enables the nurses to improve their services to accommodate those of patients. It's vital to note that these documentations do not just entail the health practitioner’s records but in a broad perspective contains the patient comments, recommendations and personal patient review of the services of the health institution. At CareOne Randolph Hospital Massachusetts, given a large number of patients administered yearly, it's crucial to apply proper documentation. The general essence of appropriate documentation is to enable the improvement and or provision of quality healthcare. The context of this paper is to examine the justification of proper documentation as an improvement to quality healthcare, in value-based reimbursement and also the implementation strategies affecting organizational change.

Proposal

Notably, several evidence-based approach research has concluded that proper use of documentation is an essential process in improving the quality of healthcare. According to Tuti et al. (2016), record-keeping as a health information system is poorly managed and thus cannot be effectively used in the improvement of the quality of services. Tuti concludes that proper use of documentation by promoting learning is capable of improving the quality of care. Mathioudakis (2018) also agrees with the fact that appropriate documentation is essential for the delivery of quality healthcare. Adequate use of documentation is also critical for assessing the impact of the health institutions service delivery on patient income and thus checking and reviewing the patient documentation is vital to improving clinical practice and conclusively the quality of healthcare. (Hughes, 2008). Another crucial factor to consider is that proper use of medical documentation creates a platform that aids interdisciplinary communication and value-based reimbursement that generally improve the quality of healthcare. (Aligolbandi, 2012). In this context, therefore, proper use of documentation and health records at CareOne Randolph Massachusetts will be effective in improving the quality of service delivery in the institution.

Proper Documentation in Enhancing Value-Based Reimbursement

Value-Based reimbursement refers to a payment system through which health institutions are reimbursed depending on the quality of their services. The payment system is thus based on quality and not quantity. According to LaPointe (2017), proper use of documentation maximizes the claims to reimbursement and revenue by improving the quality of healthcare. Notably, the research papers above as applied in evidence-based research showcase the fact that proper use of documentation is essential in improving the quality of healthcare. By discovering the impacts of the healthcare system on patient outcomes and also interdisciplinary communication would be effective in improving the quality of service delivery in a health institution. Because value-based reimbursement system is a payment system based on the quality of the healthcare system, proper documentation would be effective in maximizing the revenue at Randolph CareOne Hospital.

Data Evidence on the Need for Proper Documentation in Randolph CareOne Hospital.

The primary reason behind the need to introduce proper documentation in Randolph CareOne, Massachusetts, is because of the many patients the facility admits. Notably, CareOne at Randolph is known in the whole town as a major healthcare service provider presumably the best in patient care. The institution is very big, with 168 beds. (U.S. News, 2010). This implies that the patient access to the hospital is extremely high. According to CareOne (2020), the facility serves a diverse population receiving 200000 patients a year. In such an environment with many patients, proper documentation could be a problem and thus may lower the quality of services in the institution. It's, therefore, crucial for the facility to incorporate techniques that will serve to improve the process and use of documentation effectively and thus improve the quality of healthcare.

Inter-professional Strategies

To implement proper use of documentation in CareOne at Randolph, the facility needs to implement strategies that can ensure there's quality service delivery through the technique mentioned. Inter-professional collaboration refers to the union of different professions, including the members of the community in ensuring the success of the implementation process of proper use of documentation in CareOne. Inter-professionals should possess a committee of ethics that drafts the way the professions interact with each other in settling differences and enhancing communication. (AMA, 1994). Three strategies can be employed in the use of interdisciplinary collaboration; these are didactic program, community-based experience and inter-professional simulation. Didactic program deals with building the teamwork of inter-professionals, impact of culture on healthcare and also patient-centred care. The community-based experience focuses on how the available resources impact the individuals while inter-professional simulation works with the development of clinical team and communication skills. (Bridges, 2011). Conclusively, these techniques are essential in implementing proper use of documentation in CareOne at Randolph.

Strategy Defense

Several advantages can be accrued through the use of these strategies in CareOne at Randolph. For instance, the didactic approach which focuses on building teamwork of inter-professionals can greatly improve the quality of healthcare through role clarity, trust and confidence and collective leadership they are capable of overcoming personal differences and healthcare challenges and thus ensure proper use of documentation. (Bosch and Mansell, 2015). Community-based experience which focuses on the use of available resources and understanding the culture as well is essential in improving the quality of healthcare by educating the community to apply what they have, and also complex patients are taught self-care, (Eggenberger et al., 2019). Lastly, the use of professional simulation will also serve the function of didactic strategy in enhancing proper collaborations, especially to ne nurse from school. (Paula et al., 2018). All these strategies have the function of improving the quality of healthcare through the use of proper documentation in CareOne at Randolph.

Change Theory

According to Mitchell, (2013), Change theories are planned strategies the affecting the implementation of policies that improve the quality of healthcare. Notably, it's imperative to note that the success of an intervention would be solely dependent upon the use of strategic change theories. In the context of CareOne at Randolph, Lippitt's change theory has been used in the development and identification of the use of proper documentation in improving the quality of healthcare. The 7 phases of Lippitt's approach are indeed crucial in this intervention. Phase one, two and three were essential in identifying the need for proper documentation and ascertaining the need and capacity for change. The last four steps will be necessary for the implementation and evaluation exercise of the adequate use of documentation in CareOne at Randolph. Notably, this theory follows a strategic plan of assessment, planning, implementation and evaluation. (Mitchell, 2013). This theory will, therefore, definitely aid the implementation process.

Change Assessment

Health practitioners need to evaluate whether the new interventions or change programs that have been implemented are working or they need improvement. Evaluation is necessary for identifying malfunctions in new systems while aiding the development of the change process. (Olea et al., n.d). In the event of introducing proper use of documentation in CareOne at Randolph, Massachusetts, the appropriate assessment technique is the use of tracer methodology. (Olea et al., n.d). This method follows up on the entire health care process while pointing details on communication, coordination and the application of the intervention in improving patient outcomes. Tracer methodology will be essential in the whole process of evaluating the proper use of documentation in CareOne at Randolph because it will assess the institution from every department while monitoring the progress of each. (Olea et al., n.d). Being such a large organization, the tracer methodology will be a critical evaluation technique.

Conclusion

The essence of every service provider in the health sector is to ensure the administration of quality services. The implementation of proper use of documentation in CareOne at Randolph is to enable the improvement of their services. Several evidence-based research showcase that appropriate use of documentation certainly improves the quality of healthcare and will thus increase the value-based reimbursement. CareOne being large will work best with inter-professional collaboration in enhancing the documentation process. Lippitt’s change theory, together with tracer methodology, are practical implementation and change theories of the program.