GME Patient Safety Quality and Innovation Symposium

INTRODUCTION: Frail patients are at significantly elevated risk of major postoperative complications and mortality. The Risk Analysis Index (RAI) Frailty Index is a validated tool for preoperative frailty assessment. In the Veterans Affairs (VA) system, the Surgical Pause Practice is requiring preoperative frailty index documentation. However, as of September 1, 2025, no frailty scores were being recorded on general surgery cases at our VA. Because the preoperative clinic represents the most consistent and controllable point of contact for surgical patients, this project focused on clinic-based workflow integration to maximize impact. This project aimed to increase documentation of preoperative RAI frailty scores among general surgery patients from 0% to 25% over a 4 month time period. METHODS: This quality improvement project used the Institute for Healthcare Improvement’s Model for Improvement. An interprofessional team of Chief Residents of Quality Improvement and Safety, licensed vocational nurses (LVNs), and general surgery residents and faculty was formed. Process mapping and stakeholder interviews identified that lack of provider knowledge about frailty and no incorporated frailty evaluation in clinic workflow contributed to an absence of frailty data. To address these barriers, providers were first taught about the frailty index during our bi-weekly conference. Then, a standardized workflow was implemented to integrate frailty assessment into routine clinic operation. A patient-facing questionnaire derived from the RAI frailty index and a note template in the Computerized Patient Record System (CPRS) were developed. LVNs administered the questionnaire to all eligible patients during intake. Eligible patients were those being evaluated for potential surgery. Excluded patients were those presenting for post-operative follow-up or being managed nonoperatively. Providers then conducted their usual clinical evaluation. If a patient was deemed appropriate for surgery, providers used the completed questionnaire to input a frailty index note in CPRS. Iterative Plan-Do-Study-Act (PDSA) cycles were conducted to refine implementation. The primary outcome was the percentage of general surgery cases with a documented frailty index. The process measure was questionnaire completion. A balancing measure of clinic workflow impact was assessed qualitatively. RESULTS: From February 1, 2026 to February 28, 2026, 63 eligible patients were identified and booked for surgery. 20 patients had frailty indices recorded during this time frame, representing a 31% increase from baseline. Questionnaire completion reached 100% of eligible clinic patients. Two qualitative balancing measures were identified. First, the availability of clinic supplies initially impaired questionnaire completion, rectified on subsequent PDSA cycles with more supplies. Second, turnover among trainees led to inconsistent access to the RAI calculator, intermittently limiting completion of frailty documentation. CONCLUSION: A patient-facing questionnaire plus clinician education and workflow integration can lead to improved frailty screening for general surgery patients. Embedding the questionnaire within existing team roles, specifically LVN clinic intake, was critical to success. Limitations of this study include single-clinic implementation, short follow-up duration, and reliance on rotating trainee teams, which may affect sustainability and reproducibility. Future work will focus on standardizing access to the RAI frailty calculator and expanding implementation to other surgical clinics and non-clinic areas within our hospital.