Removing Subjectivity from Clinical Decision-Making at Chart Review Time

In medicine it’s all about discharge planning.

Some agencies subscribe to the idea that discharge planning should start from the 1st encounter because patients want solutions to their problems, sooner than later, with the proviso that solutions remain persistent.

When a patient has multiple issues, particularly issues that span medical specialties, the usual result is a problem list where each problem is separately dealt with using a “best practice” protocol that was evolved for that specific problem.

It is fairly common that the application of a particular “first line” protocol to one problem may be contraindicated because of elements/actions that negatively impact elements/actions in another problem (i.e  Pt has problems sleeping at night, medications are prescribed, Pt now sleeps like a log but is drowsy during working hours with the result that the main complaint has now shifted to job loss avoidance).

Contraindications/warnings can exist from the start or can evolve as improvements of symptoms/signs related to one problem proceed at the expense of symptoms/signs that are related to another problem.

None of this is rocket science until comes the time to predict patient discharge.

Given a list of problems, discharge should reasonably take place when “most” of the problems have resolved.

The question is how to map individual problems to sub-goals and how to assess progress toward attainment of sub-goals and the overall “discharge” goal.

Consider the following “figure of merit” matrix approach for the sleep problem highlighted above.

The Tx planning/treatment might go like this:

Goal            : Discharge when Pt is regularly sleeping more than 6 hours per night

Sub-Goal  1: adapt to no snacking less than 1 hour before bedtime
Sub-Goal 2:  adapt to performance of relaxation therapy in the evening
Sub-Goal 3: back off on meds as sleep pattern improves

Using the principles highlighted in “ Adaptive Case Management Earned Value Matrix Model“ at the Tx team might assign relative weights of 20/30/50 for sub-goals 1-2-3 for the Sleep Discharge example.

At chart review time, all that is required from clinicians is the progression of three assessments toward sub-goals 1-2-3 using attainment measures of 0-25-50-75-100 and the built-in algorithm will yield a calculated assessment at the “Discharge” Goal level.

Practical Use of Figure of Merit matrices for Healthcare Professionals

Whereas there is nothing specific about the approach as applied to the area of medicine, the usual context is each Patient will have an EMR and the calculator is best stored at the Patient EMR record for easy access and non-disruptive access.

If the EMR being  used is able to snapshot details of  all encounters to an e-Hx then it becomes relatively easy to plot the trend toward attainment of sub-goals and the overall goal.

As a consultant sitting in on occasional Chart Reviews, I find that an organized approach to progress assessment saves time and adds consistency to decisions relating to patient discharge planning.


Management consultant and process control engineer (MSc EE) with a focus on bridging the gap between operations and strategy in critical infrastructure protection, healthcare, connect-the-dots law enforcement investigations, job shop manufacturing and b2b organizations. (C) 2010-2017 Karl Walter Keirstead, P. Eng. All rights reserved. The opinions expressed here are those of the author, and are not connected with Jay-Kell Technologies Inc, Civerex Systems Inc. (Canada), Civerex Systems Inc. (USA) or CvX Productions.
This entry was posted in Adaptive Case Management, Decision Making, FIXING HEALTHCARE, Process auditing, Productivity Improvement and tagged , , , , , . Bookmark the permalink.

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