QA Best Practices Tool Kit Task Force

The Back Story QA Summit

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Locating QA Best Practices Info

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Healthcare Documentation Quality Assessment and Management

Best Practices – July 2010

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Dissecting the Document Principles of QualityFactors Affecting QualityPersonnelAssessment Policies and ProceduresSampling GuidelinesError Categories, Definitions, ScoringContinuous Quality Improvement Recommendations

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

PDCA (Shewhart Cycle or Deming Circle)PLANDOCHECKACT

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Principles of Quality Verifiability DefinabilityMeasurabilityConsistencyIntegrity

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Quality Assurance GuidelinesAccurate and complete medical recordsTimely and accessible distributionStatistically valid samplingAuditing applied to all documents, however

createdConsistent unbiased reviewError values consistent with definitions hereinConsistent communication regarding errorsAvailability of reference materials and

account specificationsThe Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Comprehensive Quality Assurance ProgramsProactiveEducationalRealistic, scalable, and financially feasibleSimple and easy to implementSecure and confidentialInclusive of all aspects of the author-to-text

processReportable for tracking and trending purposesTimely

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Factors Affecting Quality

The Author ExperienceEquipmentPatient DemographicsAccount SpecificationsResources

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

BLANKS ___VALID INVALID

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Personnel The Quality Players

- Medical Transcriptionists - QA Editors / Supervisors / Managers- Support Staff / IT - Healthcare Providers - Administration / HR - Trainers / Instructors - Educational Institutions

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

QA GuidelinesPolicies and Procedures

- Concurrent Review- Retrospective Review- Flagged Documents- Feedback - Author Assessment

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Sampling GuidelinesStatistically Valid Sampling

- Random- Sample Size

1% per month recommended95% confidence level0.851 margin of error

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Error CategoriesCritical Errors

Affect patient safety, care, or treatment

Noncritical Errors Have an impact on document integrity

Feedback Errors / Educational Opportunities Do not change meaning or affect patient care

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Critical Errors

Terminology MisuseOmissions/InsertionsIncorrect Patient Demographics or Author Identification

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Noncritical Errors

MisspellingIncorrect VerbiageFailure to FlagProtocol FailureFormatting/Account Specifications

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Feedback Errors / Educational OpportunitiesGrammarPunctuationCapitalizationPluralsRun-on/fragment sentencesAbbreviationsSlangInconsequential typos and omissionsIncorrect word forms

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Scoring Error Value from 100 Method

- If same error repeated, count only once- Score of 98 is considered passing- Deduct 3 points for a critical error- Deduct 1 point for a noncritical error- Deduce 0 points for an instructional

error Any report with a critical error should fail.Pass/Fail vs Scored Audit

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Continuous Quality Improvement Process

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Quality Improvement StrategiesSet quality assessment intervals

Monthly, quarterly, semiannually, or annuallyCustomize to individualAddress system wide problems

Areas to be addressedTechnical systemsAuthor issues (See also Dictation Best Practices

Tool Kit)Account specificationsMT concerns

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Steps to ImplementationImportance of Adopting QA Best PracticesGetting StartedMaking the Transition Transition Tools

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Importance of Adoption• Changing world

EHR Cost reduction

• Need for new best practicesWork for patient safety, focusing on

critical errors impacting patient care• What the new QA Best Practices do

Consistent, verifiable standards for all modes of document creation.

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Getting Started

Evaluate current system Work to overcome barriers Encourage a cultural shift Explain scoring methodology and rationale

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Transition Techniques and Tools

“Why the Changes” HandoutAdoption GuideChecklistsScoring SpreadsheetScoring Spreadsheet Video

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Recommendations Apply principles of qualityAssess factors affecting quality Establish clear policies and proceduresDevelop a feedback mechanismProvide training and mentoringFollow a quality assessment schedule Compile, track, and analyze QA data

Remember – PDCA!

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

QUESTIONS?

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

THANK YOU!

The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit