Vol. 14 •Issue 6 • Page 16
Quality Counts in Medical Transcription
By Brenda J. Hurley, CMT, FAAMT
The purpose of a quality assurance (QA) program in medical transcription is to provide quantifiable, credible, verifiable and measurable results that are designed to enhance the medical transcriptionist’s (MT’s) skills and provide an improved product, the health care document. Medical transcription is not an exact science, and although technology plays a role in enhancing it, it does not happen solely by any machine. Medical transcription is an interpretation of the spoken medical language.1 Skills include a generous knowledge of English usage and grammar, understanding of medicine and the medical language, good listening and intuitive skills in capturing not only what was said, but instead what was meant to be said. MTs must have the ability to stay focused and to concentrate for long periods of time with attention to detail, and possess an eagerness for learning new information as the world of medicine changes every day. A QA program is a valuable educational tool for improving skills. Improved skills means improved performance and productivity.
The benefits of such a QA program are many:
•Important for patient safety.
•Better competitive positioning within the medical transcription industry.
•Improved product provided to cur-rent (and future) customers (patients and physicians).
•Training and improved medical transcription skills.
•Morale of the individual MT can be enhanced. The critical issue here is that the QA program must never be perceived or intended to be punitive, only educational.
•Provide better standardization of the product organization-wide.
•Eliminates duplication of effort and provides a consistent message.
Here are some important elements to include when starting your QA program.
1. Set goals and objectives of the QA program. What is it that needs to be accomplished, and what are the results you want to achieve?
•The Statement on Quality Assurance for Medical Transcription by the American Association for Medical Transcription (AAMT) recommends the following goals: 100 percent accuracy with respect to critical errors; 98 percent accuracy with respect to major errors; 98 percent accuracy with respect to all errors in the report.2
•The QA review process must include comparison of the transcribed document with the dictation. Proofreading of reports is not equivalent to a QA review.3
2. Establish written definitions for types of errors, guidelines for scoring of errors and the process used for calculating the numeric score.3
•AAMT defines the following: critical error is one that potentially could compromise continuity of care, such as medical word misuse or omitted dictation; major error is one that compromises the integrity of the document without risk to patient care, such as misspellings, most demographic errors, and formatting errors; minor error is one that compromises neither patient care nor document integrity but represents an area of recommended improvement to the MT, such as capitalization, punctuation and other minor style and grammar errors.2
•Use The AAMT Book of Style as a reference tool for all MTs, to assure a consistency in the style used and to add credibility of the document transcribed.4
3. Establish written guidelines for style. Develop a list of standard (required and/or preferred) references. This eliminates confusion as to preferred usage and instructions for the MT to follow.
•When evaluating style, punctuation or grammar, The AAMT Book of Style is the industry standard.2
•Other references (electronic and/or hard copy) should include: an English dictionary, a medical dictionary, a laboratory book, a pharmaceutical book, a surgical or equipment word book and an abbreviation, acronym and eponym book.
4. Have the right (qualified) person doing the QA review. When applicable, have a corporate-level QA director responsible for coordinating the QA program through local or departmental QA managers, team leaders or supervisors.
5. The process must be fair, objective and understandable. It must be done in the same manner within all offices and all departments in order for corporate-wide data to be valid. Evaluation of the process by the QA managers is ongoing as clients and staff changes occur. Develop an exceptions list for situations where conditions render a fair evaluation impractical (i.e., poorly re-recorded dictation, loud background noises that distort the dictation, etc.).3
6. Use frequent communication, whether in person, over the telephone or through e-mail, to improve the process and assure consistency in applying standards throughout the organization. MTs should have the ability and opportunity to challenge their QA review.3
7. The results must be valid and quantifiable. These scores must be obtained in the same manner in all offices or departments in order for corporate-wide data to be valid. Periodic audits of reviews performed must be done in order to verify the consistency of the scoring process used by all QA managers.3
8. Be able to report results corporate-wide or institution-wide (by individual, by office, by department, by client/dictator) to internally track progress and/or schedule modification activities (i.e., in-services, counseling, written communications, etc.), and externally track progress with clients/physicians (i.e., customer satisfaction surveys, QA report updates, comment cards, eagle-eye inspection stickers, evaluation forms, etc.).
9. Always keep the focus on the benefits of the QA program. A proactive positive attitude will overcome the negativity factor. Send a consistent, clear message that the QA program is implemented for the educational value, to enhance skills and to improve your product. Threatening and/or bullying staff (real or perceived) will not gain the results that are required or desired. Consider the following ways to enhance continuing education:
•Hints and tips for transcribing difficult dictators or specialties.
•Self-assessment exercises with a focus on common errors or questions presented by MTs. When answers are provided, be sure to include references (i.e., books, Web sites, etc.) as these can serve as a future resource to the MTs and QA staff.
•Perform workshops on style and professional practices using The AAMT Book of Style as your guide and reference.
•Periodically list new drugs and terminology in corporate newsletters or e-mail blasts.
•Publish book reviews of references in corporate newsletter or e-mail blasts.
•Encourage participation in local AAMT component association activities.
•Join your professional association and read its literature and journals.
As members of the health care documentation team, quality assurance in medical transcription is not an option, but a responsibility to those who employ MTs (or contract MT services) and to the patients that entrust us. Our product, the interpreted, transcribed health care record, is a reflection on the quality of care provided by the health care institution and the health care provider.2 As critical clinical decisions are based on the information documented through the dictation and transcription process, the stakes are high. Undeniably, for health care excellence and consistent patient safety, quality counts!
1. MTs Partners in Medical Communication, AAMT 2002.
2. AAMT Statement on Quality Assurance for Medical Transcription, published May 2003.
3. ASTM E2117-00: Standard Guide for Identification and Establishment of a Quality Assurance Program for Medical Transcription.
4. The AAMT Book of Style, second edition, published in 2002.
Brenda J. Hurley is director of MT Development for MedWare Inc., Maitland, FL, and chair of ASTM E31.22 standards committee. She is also a past-president of the American Association for Medical Transcription (AAMT).