Quality Assurance for Medical Transcription
Linda A. Byrne, CMT
One of the secrets to running a successful medical transcription business or department is knowing how to demonstrate the quality of work produced–that transcripts produced are 99 percent accurate or better; that production levels are reasonable and turnaround meets or exceeds expectations; and that the transcribed records will stand up in court if challenged, that they are as accurate as the dictation that was provided. But how do you measure accuracy, and how do you assure that work produced is up to snuff? In two words: quality assurance (QA).
For years, medical transcription supervisors and health information managers have been asking for guidance in setting up a quality assurance program for medical transcription. Staff at the American Association for Medical Transcription (AAMT) have been asked for a model QA program more than once, but we’ve not been able to provide the specifics and details that callers would like. Supervisors wish we could provide a recipe for determining how to review and rate the work of medical transcriptionists (MTs).
If they are to set up a QA program to monitor the work of individual MTs as well as the entire department or business, they want to do it right. They ask for numbers and definitions. What are acceptable production quotas by the day, week or month, and are they measured by the line, character, page or dictation time? What are acceptable accuracy levels? How many mistakes are too many and what do they look like?
There is no one right answer for these questions because departments, individual MTs, dictation styles, and volume and complexity of work vary too widely to fit one pattern. So does that mean there are no standard guidelines at all for those supervisors who want to design a QA program? For now, but there is a light on the horizon.
A standard guide is in progress, being written by the task group on processes in ASTM’s E31.22 subcommittee on Health Information Transcription and Documen-tation. With the working title of Draft Standard Guide for the Identification and Establishment of a Quality Assurance Program for Medical Transcription, the document outlines the essential components of a QA program. It describes factors that should be considered when evaluating individual MTs and the processes responsible for producing health care documentation.
The task group determined that quality documentation is dependent on four distinct processes–dictation, transcription, management and quality assurance–and the document devotes a major section to each. It des-cribes the responsibilities and obligations of the respective personnel (author, transcriptionist, manager, quality reviewer) that lead to quality health care documentation. While discussing error types and accuracy percentages involved in a QA program for medical transcription, the guide states that it is the responsibility of management, with input from MT staff, to establish standards for:
* errors, omissions and inconsistencies;
* turnaround time;
* formats, style and editing;
* frequency and volume of work to be reviewed; and
* productivity requirements.
The goal of every medical transcription department or business is (or should be) to provide accurate, complete, consistent health care documentation in a timely manner, making every reasonable effort to resolve inconsistencies, inaccuracies, risk management issues and other problems. A well-planned and executed QA program can help make that happen.
* For more information on ASTM activities, call AAMT at (209) 551-0883 or ASTM at (610) 832-9500.
Linda A. Byrne is senior director of certification at AAMT and co-chair of the E31.22 task group on processes.