MOC Tip of the Month
Suzan Schneeweiss

Dive into your patient records to improve your practice

MOC Tip of the Month: Suzan Schneeweiss - Region 3

Completing a chart audit with feedback is an excellent way to improve an aspect of care in your practice, and engage in self-assessment for Section 3 MOC Program credits at the same time.

A chart audit is an analysis of your patient medical records — electronic and/or paper — to see what has been done and to determine if it can be done better. You are essentially measuring the quality of the care your practice provides, in order to improve it.

Here is my seven-step process to quality improvement by chart audit. I have also included examples from my perspective as a pediatrician to help you visualize how to implement the process:

1. Select a topic:

   Ideally, the topic should interest both you and your practice. Ask yourself what is being done (or not done) there that could potentially be done better. Are there any problems that need addressing? What issues are high-risk and high-frequency?

   For example, as a pediatrician, I might like to measure how well my practice is meeting established national benchmarks for vaccine recommendations.

2. Determine what you will measure and your benchmarks:

   In this step, define your assessment question and select at least three benchmark performance measures or standards of care that you will compare against your performance-in-practice.

   For example, the Government of Canada and my national specialty society — the Canadian Paediatric Society (CPS) — have flagged children under five as being at higher risk of flu complications. I might decide to measure how often the influenza vaccine was offered and given to or declined by my patients in this age group over the past two years. If that was my focus, I would do a literature review to identify available national benchmarks for vaccines. I’d start by reviewing the CPS’s recommendations and the Public Health Agency of Canada’s immunization schedules.

3. Collect your data:

   Next, identify your patient population and your sample size; then, pull your patient charts. Review the charts that meet all of your selection criteria and record your findings.

   In my example, I might collect data from a random sample of at least 10 charts belonging to my patients aged six months to five-years-old. I would then record how many of them were offered and received or declined the flu vaccine in my selected timeframe.

4. Compare your data against your measures:

   After you collect your data, compare it to established benchmarks. Your benchmarks will depend on your topic and the performance measures you selected.

   Sometimes benchmarks for comparison do not exist or are not readily available. If that is the case, you can either revise your audit so that it is comparable to existing measures or use your results as a baseline against which you can compare future audit results.

   For example, if my audit determines that the flu vaccine was not offered or given to my sample population as recommended by established benchmarks, I will know that there is room for improvement in my practice and a need for further investigation. 

5. *Obtain feedback:

   Once you have summarized and compared your practice’s performance against the measures you selected, share your findings with a colleague, peer or mentor in your practice or specialty.

   For example, I might ask one of my colleagues at the University of Toronto to review my data and help me draw conclusions.

6. Identify outcomes and apply results:

   After going over the results with your reviewer, consider if there’s an area of your practice that you can improve upon. Also consider what actions you could implement to close performance gaps in your practice.

7. Document your chart audit in your MAINPORT ePortfolio:

   Last but not least, log in to your MAINPORT ePortfolio and record your learning outcomes using the “Chart audit and feedback” option. I recommend you do this as soon as possible, while your learning is still top-of-mind.

A chart audit can illuminate positive ways to improve your practice. By breaking it down into steps, it becomes more manageable to carry out and much easier to implement results!

*Note: Step #5 is especially important. Obtaining feedback is what makes a “chart audit with feedback” a Section 3 assessment opportunity (three credits per hour) instead of a Section 2 self-learning opportunity (two credits per hour). However, if you skip this step, you can still claim learning from this exercise as a personal learning project under Section 2.

Fellow readers, do you have a MOC tip that you would like to share with others?

Fellows, do you have a MOC tip that you would like to share with others? Contact communications@royalcollege.ca with your tip. If we use it, we will send you a free piece of merchandise from our Insignia collection.