Improving Clinical Documentation through Monthly Audits in Butare Teaching Hospital, Rwanda

Abstract

Creditable and timely clinical documentation is an essential component in patient care quality improvement. We designed and implemented a practical clinical audit process as a way of measuring and improving quality of clinical care in Rwanda; as well as to enhance the compliance score according to the hospital accreditation standards. The project took place at Central University Hospital in Butare (CHUB). A pre- and post-intervention study was used to examine the impact of creating a standardized auditing system on the department clinical auditing completion rate and the accreditation standards compliance rate. Once audit results are entered into the MS Excel tool created, the completion and accreditation compliance rate are automatically computed by the system. The results were presented in the monthly QI meeting as feedback. Two sets of measures were collected: 1) department clinical auditing completion rate, and 2) the COHSASA standards compliance rate. The completion rate of monthly audit reports increased from 57% (pre-intervention) to 96% (post-intervention), P < 0.000. The hospital-wide average accreditation standards compliance rate for clinical documentation also significantly improved from 27% to 60%, P = 0.000. Providing departments a simple and user-friendly clinical documentation auditing tool can enhance the completion rate of audit reporting at no additional cost to the hospital. Hospital leadership plays to support and organize the system are crucial. These data can be used for evidence-based decision making to improve completeness and accuracy of clinical documentation and thus comply with accreditation standards.