Identification of Local Problem
The EGS Service at the University of Kansas Health System (TUKHS) has coverage provided by a series of rotating residents, attendings, and various consultant services. The constant changing of team members resulted in inconsistent use of established Patient Management Guidelines (PMGs).
Context of the QI Activity
The EGS Program at TUKHS implemented a series of PMGs aligning with common EGS diagnoses using current literature and best practice guidelines. The PMGs were vetted and approved through the EGS Multidisciplinary Committee and formally published on the hospital’s intranet. Checklists were developed from each PMG, identifying any ‘must have’ items/tasks from approved guideline.
What were the interventions?
Patient cases are identified for review at Morbidity and Mortality Conference (M&M) based on potential or known complications, or surgeon request. The EGS Performance Improvement Coordinator (PIC) completed a thorough review of each patient’s hospital course in tandem with a review of any applicable PMGs for that hospitalization, identifying deviations from standard of care. Each case review included the previously established PMG checklist, including checked or blank items, which indicated the adherence or deviation from our PMGs. Findings were presented at EGS M&M Conferences and discussed amongst surgeons, residents, Advanced Practice Providers (APPS), and administrative personnel, identifying any reason for deviation, suggestions for revision, or need for education.
Cost and Funding Sources
The intervention was free, barring the calculated time and salary of the EGS PIC.
Overall Results and Analysis
The PMG audit process began in January 2024 and has resulted in 11 revisions to current PMGs and development of 6 additional PMGs as of March 2025.
Limitations
FTE allocation and time to review charts are very dependent on each organization. If there is a dedicated FTE for EGS chart review, the audit process should be feasible, as audits are completed during the chart review process.
Lessons Learned
The EGS Program at TUKHS has developed multiple PMGs for the management of common EGS conditions and implemented a method for continuous audit of EGS PMGs with each patient review at weekly M&M conferences. The continuous audit process provides a more impactful reminder to the rotating EGS team to follow our current PMGs, provide a platform for suggestions or revisions, and improve overall adherence among our team to further enhance quality patient care.
