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 Quality Factors Affecting Quality Personnel Assessment Policies and Procedures Sampling Guidelines Error Categories, Definitions, Scoring Continuous Quality Improvement Recommendations The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

PDCA (Shewhart Cycle or Deming Circle) PLAN DO CHECK ACT The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Principles of Quality Verifiability Definability Measurability Consistency Integrity The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Quality Assurance Guidelines Accurate and complete medical records Timely and accessible distribution Statistically valid sampling Auditing applied to all documents, however created Consistent unbiased review Error values consistent with definitions herein Consistent communication regarding errors Availability of reference materials and account specifications The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Comprehensive Quality Assurance Programs Proactive Educational Realistic, scalable, and financially feasible Simple and easy to implement Secure and confidential Inclusive of all aspects of the author-to-text process Reportable for tracking and trending purposes Timely The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Factors Affecting Quality The Author Experience Equipment Patient Demographics Account Specifications Resources 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 Guidelines Policies and Procedures - Concurrent Review - Retrospective Review - Flagged Documents - Feedback - Author Assessment The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Sampling Guidelines Statistically Valid Sampling - Random - Sample Size 1% per month recommended 95% confidence level margin of error The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Error Categories Critical 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 Misuse Omissions/Insertions Incorrect Patient Demographics or Author Identification The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Noncritical Errors Misspelling Incorrect Verbiage Failure to Flag Protocol Failure Formatting/Account Specifications The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Feedback Errors / Educational Opportunities Grammar Punctuation Capitalization Plurals Run-on/fragment sentences Abbreviations Slang Inconsequential typos and omissions Incorrect 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 CQI ReviewReviseCommunicateMonitor The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Quality Improvement Strategies Set quality assessment intervals Monthly, quarterly, semiannually, or annually Customize to individual Address system wide problems Areas to be addressed Technical systems Author issues (See also Dictation Best Practices Tool Kit) Account specifications MT concerns The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Steps to Implementation Importance of Adopting QA Best Practices Getting Started Making 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 practices Work 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” Handout Adoption Guide Checklists Scoring Spreadsheet Scoring Spreadsheet Video The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

Recommendations Apply principles of quality Assess factors affecting quality Establish clear policies and procedures Develop a feedback mechanism Provide training and mentoring Follow 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