Slide 1
This week, we are focusing on quality management aspects as they pertain to various functions in the HIM department.
Slide 2
You should remember from HIT141 Health Information Operations that some of the basic functions in the HIM department are processing of medical records, whether paper, hybrid, or electronic; record analysis; transcription; release of information; coding of diagnosis and procedures; maintenance of indexes and registries; and collaboration with other departments. In this week’s screencast, we are bringing together the separate reading assignments from Chapter 8 and trying to create a better picture of what quality and compliance mean for these functions.
Slide 3
Quality control starts with developing productivity and accuracy standards. Some examples of standards would be
These standards can be determined based on historical data of the facility or comparisons with other facilities. Employees need to know the expectations for productivity and accuracy.
Slide 4
In the hybrid environment, standards established for the paper record still apply; however, new standards are introduced, primarily related to scanning of the records, quality of the images, and the turnaround time for the records to be scanned and available electronically.
A unique monitoring consideration is a quality check or reconciliation of the paper and the scanned documents to assure complete and clear images and accurate organization of the documents in the folders they belong to.
Quality issues may be related to employees or technology. For example, an employee can miss scanning all the paper documents or barcode them incorrectly, thus sending the document in the wrong folder or even patient record. On the other side, the scanner may have poor resolution, thus leading to poor image quality. Training, audits, and equipment selection and maintenance may help resolve the issues.
Slide 5
Quality control in the EHR addresses the system design, primarily the technology or the way screens are designed for complete and accurate data capture and data output, meaning are we able to retrieve information in certain formats. In addition, processing and transmission of the information need to be consistent and reliable.
Slide 6
Health records can be analyzed by focusing on timely document completion, which is considered quantitative analysis, or by focusing on the quality of documentation, which is considered qualitative analysis. During a quantitative analysis, the analyst identifies missing documents and unsigned documents and flags the record for completion. During a qualitative analysis, the reviewer looks for inconsistencies, such as whether medications were administered as ordered by the physician. Attention is often directed to documentation of clinical protocols. For example, for a patient scheduled for surgery, was an antibiotic given 1 hour prior to the first incision?
Slide 7
When it comes to transcription, quality means accurate and timely transcription of the dictations. What we are looking for is minimal wrong terms, misspelling, and grammar errors; correct formatting; and quick turnaround time, especially for documents of high priority, such as history and physical and operative reports.
Slide 8
Turnaround time is also important in release of information, especially in cases when patient care is at stake. In order to comply with the federal HIPAA requirements, a healthcare facility needs to prepare and release the required health information within 30 days for records stored on-site and 60 days for those stored off-site. When the HIM department cannot keep up with the volume of requests, outsourcing may be considered.
Slide 9
In clinical coding, turnaround time is directly related to reimbursement. In addition, accuracy of coding is a quality indicator. Hospitals usually strive for a 95–100% accuracy rate. In order to achieve such a rate, regular internal audits by a coding supervisor, lead, or senior coder are considered, as well as external auditing, usually done by coding companies for a payment.
Slide 10
Similarly, accuracy and timely data abstraction and reporting is expected and required for cancer registry, birth registry, trauma registry, minimum data sets (MDS), and data collected for core measures, such as pneumonia, myocardial infarction, congestive heart failure, stroke, and so forth.
Slide 11
HIM professionals are usually at the forefront of data collection and analysis; however, they can also contribute by participating in performance improvement projects; preparing reports, especially at times of accreditation and licensing surveys; focused reviews; or physician reviews for credentialing purposes.
Slide 12
A quick note needs to be made regarding quality control and the workflow. New systems are frequently implemented, and they create a need for a new routine and process. For example, once a hospital implements an EHR, a qualitative review of the medical record can be done from anywhere. The reviewer does not have to interfere with patient care when asking for the medical record; instead, he or she can access it from the workstation or a portal. Also, compliance with meaningful use is expected, such as providing patients with a visit summary or giving them access to their records through a portal.
Slide 13
The common thread in all of these activities is establishing standards and criteria that represent an acceptable level of performance, collecting the data and monitoring performance, reporting, analysis, and intervening with corrective action. What’s often forgotten is recognition for high quality. This is important because it helps promote positive behaviors and practices and creates a culture of high quality and better compliance with various standards and requirements.