Department of Medicine Performance Improvement

1
Department of Medicine Performance Improvement

• Record Completion

2
Regulatory Background

• DOH, The Joint Commission and TUH MS Bylaws
  require record completion w/in 30 days of
  discharge.
• Any incomplete record gt 30 days is considered
  Delinquent.
• TJC DOH require monitoring and reporting of
  delinquent records.

3
DOM MRD Joint Efforts

• Early process developed w/ DOM Chief Dr. Karen
  Lin
• Ongoing weekly communication with Chief Residents
  regarding delinquent residents.
• MRD paging of delinquent residents.
• Chiefs direct communication with delinquent
  residents.
• Goal decrease need for MIS suspension.

4
Technology Enhancements

• 1/07 Implementation of electronic record
  completion module in Alpha Imaging.
• Physician direct access to incomplete record
  lists via Alpha sign-on.
• e-Sign capability.
• Auto e-mail notification of outstanding records.
• waiting for Dr to dictate upgrade.

5
Data Trending
6
Delinquent Record Detail
  Resident Attending
Date Dictations Signatures
1/11/2007 161 179
3/28/2007 130 156
6/27/2007 88 152
10/31/2007 26 92
1/30/2008 62 41
4/28/2008 84 22
7/31/2008 43 38
10/31/2008 73 44
1/30/2009 36 44
4/17/2009 37 44
7
DC Summary Next Steps

• DC Summary simplification process for short stay
  cases (lt 5 day LOS)
• Joint CHF Workgroup and Medical Record Committee
  Recommendation
• Address CHF CORE DC medication documentation
  requirements
• Developed with DOM Chief Residents

8
MIS DC Summary/DC Instruction

• MIS template document created resident
  completes for discharge
• DC instructions.
• DC Summary (lt5 day LOS).
• Auto fax to PCP.
• Signed by attending physician and complete record
  without further dictation.
• DC summary dictation still required for LOS 5 day
  and greater.
• Anticipated transcription savings 52 K per year
  --3 4 day LOS - 23 volume.