A Solution to the Problem of Undictated
Operative Reports by Residents
Max M. Cohen, MD, Adelaide A. Ammon, MPH,
Detroit, Michigan
PURPOSE:
The objective of this study was to re-
duce the number of operative reports assigned
to the surgical residents but not dictated within
48 hours by 80% within 6 months.
METHODS:
A before-after trial was conducted in a
teaching hospital (part of a major academic
medical center) in an urban setting, of a complex
intervention based on a theoretical framework
for behavioral change. Data were collected for
more than 6 months before the intervention, and
then in three separate time periods during the
next 18 months. The intervention, lasting 41
weeks, and directed specifically at undictated
operative reports, comprised the following: edu-
cational sessions, posting of residents’ names
with delinquency rates, attending/resident inter-
actions, telephone reminders, rewards, and pun-
ishments. The population studied comprised ev-
ery resident who rotated through the general
surgery service over a 2-year period 1995 to
1997.
RESULTS:
The mean (؎SD) number of undictated
operative reports declined progressively from 72
(؎8.3) to 6 (؎2.6). This 92% reduction was statis-
tically significant (P <0.00005). The mean num-
ber of undictated discharge summaries declined
progressively from 54 (؎11.2) to 13 (؎8.1). This
76% reduction was also statistically significant
(P <0.00005). There was a close correlation be-
tween the operative reports and the discharge
summaries (r ؍ 0.82).
CONCLUSIONS:
The performance of residents on
the surgical service in respect to operative re-
port dictation can be profoundly influenced by a
carefully targeted set of interventions based on
behavioral theory. The improved performance
can be maintained with simple reminders and
the halo effect of the intervention extends to the
dictation of discharge summaries. Am J Surg.
1998;176:475– 480. © 1998 by Excerpta Medica,
Inc.
M
ost hospitals are faced with a substantial and
continuing problem of incomplete medical
records, and struggle to deal with it.
1
This is an
important issue from a regulatory, risk management, and
financial perspective. There is little or no guidance avail-
able in the literature about how to address it. There appear
to have been no attempts to develop a theoretical frame-
work for changing physician behavior in relation to the
specific problem of incomplete medical records. The pur-
pose of this paper is to report an intervention to improve
the timeliness of dictation of operative reports by surgical
residents. It describes the theoretical framework for and
structural components of the planned intervention, and
the results obtained.
METHODS
The site of the intervention was a teaching hospital in
Detroit, part of an eight-hospital major academic medical
center. The target population was the residents rotating
through the Department of Surgery. The goal of the inter-
vention was to reduce the number of undictated operative
reports by 80% within a period of 6 months and maintain
it at least at that level.
Theoretical Framework
Behavioral models and theory offer a rational approach to
changing physician behavior and maintaining the change
once it has been achieved. The transtheoretic model
2
with
its stages and processes of change appears to be an appro-
priate model for changing resident behavior. According to
this theory, behavior change evolves through a series of
stages: precontemplation (not thinking about changing a
particular behavior), contemplation (thinking about it but
no attempt to change), preparation (making plans for a
change within a few weeks), action (recently initiated a
change), and maintenance (change sustained for 6 or more
months). The major processes thought to be usefully in-
volved at different stages are consciousness raising, self-
reevaluation, self-liberation, helping relationships, and
counterconditioning.
A second theory of interest is the organizational devel-
opment theory (OD). This is a valuable model for chang-
ing the behavior of organizations, such as hospitals. Porras
and Robertson
3
suggest that there are four stages to achiev-
ing change in an organization: diagnosis, action planning,
intervention, and evaluation. An OD approach to the
development of intervention strategies is to identify several
possible strategies and then narrow them down. This win-
nowing is based on the organization’s readiness to imple-
ment (ie, does it have the necessary resources), the avail-
ability of leverage points (where and how to intervene),
and the skill of the individual who would implement the
From the Department of Surgery, Grace Hospital, Detroit, Mich-
igan, and Wayne State University School of Medicine, Detroit,
Michigan.
Requests for reprints should be addressed to Max M. Cohen,
MD, 555 South Woodward Avenue, #902, Birmingham, Michigan
48009.
Manuscript submitted April 13, 1998 and accepted in revised
form September 8, 1998.
SURGICAL EDUCATION
© 1998 by Excerpta Medica, Inc. 0002-9610/98/$19.00
475
All rights reserved. PII S0002-9610(98)00236-0