Standardization of hypospadias documentation at a single institution: Successful implementation using a nudge intervention
Christopher J. Long, MD, Nathan Hyacinthe, BA, Natalie Plachter, BA, Dana A. Weiss, MD, Aseem R. Shukla, MD, Arun K. Srinivasan, MD, Stephan A. Zderic, MD, Jason Van Batavia, MD, Sameer Mittal, MD, Thomas F. Kolon, MD, Mark R. Zaontz, MD, Douglas A. Canning, MD.
Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Background:Improving hypospadias surgical outcomes is limited, in part, by variability in anatomic and surgical details at the surgeon and institutional level. Standardization of the documentation process from the pre-operative assessment though follow-up could lead to improved data evaluation and facilitate collaboration across institutions for less common variants. We hypothesize that we could implement a standardized set of documentation notes across our surgical team and with increased compliance through a nudge intervention incorporating an audit and feedback dashboard.Methods:In 2016 we modified our templates for hypospadias in our electronic medical record (EMR). We created specific notes for the pre-operative, operative, and follow up notes with smart data elements that capture critical details. Data elements, anatomic assessments, and complication definitions were universally agreed upon in our group prior to implementation. Our EMR was configured to provide automated data abstraction and a compliance audit and feedback report for note usage was sent to all surgeons on a monthly basis. Results:Over the course of the past 5 years, a group of 12 pediatric urologists have treated 968 patients with hypospadias. Our group This includes 770 distal and 198 proximal hypospadias variants. There have been a total of 5459 patient encounters, including 1707 pre-operative notes, 1303 operative notes, and 2449 follow up notes (immediate postoperative notes were excluded). A total of 1303 procedures have been performed during that period. Compliance was improved with provider directed feedback and achieved 90% compliance for the operative note, 95% in the preoperative note, and 80% in the follow up note (Figure 1). In the preoperative visit, physical characteristics including glans width and penile length, the degree of penile curvature, and the location of the urethral meatus are captured. In the operating room theater a broad set of data is collected, starting with the type of repair, prior surgical history, and procedural elements. Specific technical aspects of urethroplasty, glansplasty, and chordee repair are obtained. Various potential mediators of a successful repair are also included, such as the type and duration of diversion, use of barrier layers, suture type, and suture technique. Follow up notes include a specific set of questions to assess urinary, erectile, and cosmetic function. The follow up algorithm has been extended to capture true functional outcomes. Conclusion:We were able to implement a standardized hypospadias documentation process across a multi-surgeon, single-institution practice. We demonstrate that compliance with documentation significantly improved with a nudge intervention using provider directed feedback, and this process could serve as a template for widespread implementation across institutions facilitating collaboration.
Figure 1: Panel A: Operative note usage. Compliance now approaches 90% (solid line). Absolute number of cases was 246 in 2016, 253 in 2017, 262 in 2018, 274 in 2019, and 268 in 2020. Panel B: Preoperative office note compliance, solid line depicts proper documentation. We achieved 95% success in 2020.
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