QA Best Practices

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QA Best Practices

• QA Best Practices Tool Kit Task Force

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The Back Story

• QA Summit

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Locating QA Best Practices Info
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Healthcare Documentation Quality Assessment and
Management Best Practices July 2010
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Dissecting the Document

• Principles of Quality
• Factors Affecting Quality
• Personnel
• Assessment Policies and Procedures
• Sampling Guidelines
• Error Categories, Definitions, Scoring
• Continuous Quality Improvement
• Recommendations

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PDCA (Shewhart Cycle or Deming Circle)

• PLAN
• DO
• CHECK
• ACT

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Principles of Quality

• Verifiability
• Definability
• Measurability
• Consistency
• Integrity

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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

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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

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Factors Affecting Quality

• The Author
• Experience
• Equipment
• Patient Demographics
• Account Specifications
• Resources

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BLANKS ___

• VALID
• INVALID

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Personnel

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

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QA Guidelines

• Policies and Procedures
• - Concurrent Review
• - Retrospective Review
• - Flagged Documents
• - Feedback
• - Author Assessment

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Sampling Guidelines

• Statistically Valid Sampling
• - Random
• - Sample Size
• 1 per month recommended
• 95 confidence level
• 0.851 margin of error

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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

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Critical Errors

• Terminology Misuse
• Omissions/Insertions
• Incorrect Patient Demographics or
• Author Identification

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Noncritical Errors

• Misspelling
• Incorrect Verbiage
• Failure to Flag
• Protocol Failure
• Formatting/Account Specifications

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Feedback Errors / Educational Opportunities

• Grammar
• Punctuation
• Capitalization
• Plurals
• Run-on/fragment sentences
• Abbreviations
• Slang
• Inconsequential typos and omissions
• Incorrect word forms

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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

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Continuous Quality Improvement Process
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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

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Steps to Implementation

• Importance of Adopting QA Best Practices
• Getting Started
• Making the Transition
• Transition Tools

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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.

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Getting Started

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

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Transition Techniques and Tools

• Why the Changes Handout
• Adoption Guide
• Checklists
• Scoring Spreadsheet
• Scoring Spreadsheet Video

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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!

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QUESTIONS?
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THANK YOU!