Vol. 11 •Issue 15 • Page 14-18
The Speed of Health Information
Poor transcription turnaround times and delinquent medical records pushed this facility to find process improvement solutions.
By Renee Mallett, RN, MSN, JD, Debbie Murphy, MBA, Sandra Mandich and Ervanna Brugger
In early 2000, the labor market for health care professionals and other professionals became very depleted and was coupled with an extremely low unemployment rate. Licking Memorial Hospital in Newark, OH, began to lose qualified medical transcriptionists (MTs) to other competitors such as physician offices and outpatient centers that offered normal business hours and outsourcing transcription companies that offered an at-home work environment. Attempting to recruit MTs to work evenings and weekends became very challenging. The turnaround times for our inpatient and outpatient reports began to steadily climb, as did the medical record delinquency rate. An outsourcing company was utilized, but there were many difficulties. The costs to outsource dictated reports were astronomical; the quality of the transcribed report was very poor; and many dictated reports got deleted in the transmittal process.
Goals and Objectives
It became very apparent that if the medical record delinquency rate and transcription turnaround times did not begin decreasing, other unintended consequences would occur, such as patient safety issues in not having a transcribed report present, medical records unable to be coded and billed, a backlog of unfiled medical records, physician dissatisfaction, poor customer service and a decline in morale of the health information (HI) staff. Hence the following goals and objectives were established:
1. Retention and recruitment of qualified MTs.
2. Hiring of a qualified MT coordinator and front office coordinator.
3. Decrease the medical record delinquency rate from 100 percent to less than 50 percent in six months.
4. Decrease the dictation and transcription turnaround times to less than 24 hours.
5. Enhance physician satisfaction with transcribed reports as measured by the quality of the report and the transcription speed.
6. Educate physicians on the legal importance in completing their medical records in a timely manner.
The Process Improvement Initiative
The organization identified many items of extreme importance for this process improvement initiative. They included:
• Patient Safety
Primarily, patient safety was placed at an extreme risk if a physician or other health care practitioner could not have a transcribed report immediately available. Medical and health information must be readily available in an acute care institution in order to provide the adequate standard of care owed to the patient. Without a transcribed report readily available, a serious error can occur in the delivery of health care. Further, competing organizations could attract patients and clients if patient safety is compromised.
• Compliance Issues
The Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration, and private payers have strict coding and billing guidelines. Before a medical coder may code a case, adequate written documentation must be present. Attempting to code a case without proper documentation may lead to a fraud and abuse charge by the Office of the Inspector General (OIG). Hence, if a case cannot be coded, it cannot be billed and an organization’s accounts receivables will increase. The reduction of account receivable days is relevant to the organization’s clinical and financial performance because it enables the organization to improve its realized revenue and daily cash flows, invest its dollars and enhance opportunities for community and philanthropic programs.
• Physician Satisfaction and Education
The organization quickly realized that if reports were not readily transcribed and available for review by the physician and health care professional, dissatisfaction would occur between the organization and medical staff. Dissatisfaction opens the door for competitors to take advantage of an actual weakness and attract new customers. Our organization could not afford to let that occur. As we began to analyze the delinquency data, it was noted that many of the physicians were not dictating concurrently but were postponing dictating their reports. The organization wanted an opportunity to build a collaborative and informed relationship with the medical staff in an attempt to devise creative solutions in curing the problem.
• Retention and Recruitment
The organization realized that it had to be proactive in attracting and recruiting qualified MTs. The organization devised a strategy to enable the MT to be competitively paid and to work from home. The organization realized to do this, it would have to upgrade its current information system in how reports are being currently transcribed to allow the MTs to work from home. The organization noted that it was spending on average $40,000 to replace an MT who leaves the organization. The organization obtained the above figures in adding up the dollars spent in advertising the vacant position, cost of the pre-employment physical, cost to attend a four-day general orientation and the cost and time of the HI director and MT coordinator in training the new employee.
• Increase Quality and Reduce Costs
The organization knew it had no choice but to outsource the dictated reports in order to prevent system failures because of an excessive amount of dictation time on the Dictaphone system, patient safety issues and customer service issues. However, when contracting with an outsource company, quality typically decreases and costs increase. The organization knew that this would be a temporary fix, but needed to instill measures to prevent minimal dictated reports being outsourced.
Implementation Plan
The entire implementation plan can be found in Table 1 on our Web site at www.health-information.advanceweb.com.
Process Improvement Dashboards
The hospital’s mission is to improve the health of the community. The leadership of the hospital has established a planned, systematic, organization-wide approach to monitor and measure process improvement.
Every hospital department is required to create a Process Improvement Dashboard that consists of cost, quality and customer satisfaction indicators. The intent of these dashboards is to demonstrate a correlation of improving quality and decreasing cost, and they are posted every month in each hospital department and physician practice for staff to view. Each indicator on the dashboard is given a red, yellow or green color status assigned by the statistics manager. Red means that an indicator may be experiencing difficulty, while green means the department is achieving the indicator. Managers and staff collaboratively worked together in creating these dashboards. In addition, the hospital has created a Hospital-Wide Dashboard that is presented monthly to the Board of Trustees.
Senior leaders are responsible for departments under their umbrella of responsibility. On a monthly basis, they review each pertinent department dashboard to either ensure key indicators are being maintained, recognize areas of concern based on a trend or acknowledge successes achieved.
In March of 2000, the indicators collected on the process improvement dashboards were integrated into the employee’s performance evaluation. Employees are evaluated twice a year. The new employee performance evaluations are designed in which the manager works with the employee in developing four individual goals and four departmental goals. The HI director and MT coordinator are able to establish turnaround transcription times and the medical record delinquency rate as individual and departmental goals.
Retention and Recruitment
Of Qualified MTs
The organization knew that if it did not become proactive in its retention and recruitment initiatives, it would loose qualified MTs to competitors and would have difficulty in recruiting experienced MTs. Two initiatives were derived to retain and recruit qualified transcriptionists. These initiatives were the creation of a production-based transcription program and an at-home transcription program. Table 2 on our Web site, at www.health-information.advanceweb.com, displays the production-based rates that the transcriptionists are currently being paid as of March 2001. The HI director and MT coordinator obtained these rates through research and benchmarks with competing health care organization, outsourcing companies and companies that offer an at home work environment.
When the transcriptionist exceeds 40 hours in a week, the MT will receive one-half of the production rate based upon the weekly line count category. The maximum rate an MT will be paid for overtime will be 12 cents per line. The transcriptionists that have many years of experience are able to accumulate a nice income based upon the amount of lines achieved in one week. By paying on a production-based schedule, the HI department has achieved employee satisfaction and efficiencies in its wage and salary expenses and other overhead costs.
This past April, MTs began working from home. Because the organization has begun to advertise this program, the years of transcription experience has increased to 18 years.
Medical Record Review
Process and Tools
The HI department, in conjunction with the Process Improvement Center and the Call Center departments, performed a concurrent medical record review from January 2000 through June 2000. Each quarter, the volume will be verified that it qualifies for a statistically significant sample for each provider. The concurrent medical record review (see Table 3 on our Web site at www.health-information.advanceweb.com) was performed to identify any possible trends or areas for improvements.
Medical Record Delinquency Rate
On the last day of the month and on a weekly basis for suspensions, a report lists all of the charts that still have an incomplete item that are more than 21 days from the date of discharge. The report groups the charts into visit type so the hospital can track the delinquency rate by each visit type as well as an overall rate for the hospital.
A Microsoft Excel spreadsheet is used to calculate an average monthly discharge rate by visit type per the Joint Commission standards, the Medicare Conditions of Participation Rules and the medical record requirements promulgated in the hospital medical staff bylaws, rules and regulations. The actual numbers of charts that are delinquent are entered into the spreadsheet and a delinquency rate per visit type is calculated. The inpatient charts account for most of the charts included in the measurement, but we also include observation and outpatient surgery charts.
The delinquency rate is displayed on the HI Dashboard and the dashboard that is distributed monthly at the Hospital Board of Trustees meeting. The number of delinquencies received by the medical staff and for an individual physician is displayed on the monthly physician specific profiles that are given to all members of the medical staff, the President of the Hospital, Physician Chair of the Process Improvement Committee and to Legal Services. According to the medical staff bylaws, the Credentials and Executive Committees can ask a physician at any time to present at the committee as to why he or she is disregarding their medical records responsibilities.
Measurement of Specific
Dictated Reports
By July of 2000, the hospital had reduced its report turnaround times to less than 24 hours and its delinquency rate had plummeted. However, the hospital wanted to strive for better quality of services provided in the HI department. The measurements conducted by the call center nurses were a random sampling of medical records. In August 2000, the hospital created a policy to measure and track the dictation completion time of a physician in dictating the history and physical, operative report and emergency department reports. The HI department created an upfront process in monitoring the time a patient entered the hospital or had a surgical procedure to the time the physician dictated the specified medical record report. The timeliness of these reports were monitored to identify physicians who were not dictating these reports in a 24-hour time frame. This new process created a 100 percent sampling of all physicians on the medical staff.
From August 2000 through March 2001, the HI department gathered research and collected statistics regarding non-compliance in dictating the reports; provided education to physicians through physician specific profiles, informational phone calls and collegial discussions with the Chair of the Process Improvement Committee and the noncompliant physician; suspension of physicians who do not comply with these requirements after several initiatives have been taken; having the physician present to the Credentials Committee with a rationale as to why they could not complete the medical record requirements; and to further refine the policy and process to provide enforcement for infractions of non-compliance.
The Various Processes
Below are excerpts from policies on the various processes on how medical records are determined to be complete:
Research of Dictated or Signed Emergency Department (ED) Reports
1. In Meditech, run the previous day’s ED patient list by name.
2. An HI specialist will check the Dictation Job Lister system to retrieve a print out of all dictated reports and verify that list against the Daily List Patient Report. If no dictation is located using Job Lister, the hospital dictation (voice) system will then be researched.
3. The HI staff member will analyze the charts according to policy to ensure report is not present in the ED chart.
4. The HI Specialist will record the incomplete charts on two systems:
• Enter the deficiency information on an Excel spreadsheet. Enter the number of patients seen by each physician and the number of missing dictations, when applicable.
• Enter the deficiency information into the Meditech library “ED Due Chart” folder.
5. Place the incomplete charts in the physician’s folder or mailbox.
6. Names of physicians having delinquent ED reports will be kept and statistics forwarded to the Process Improvement Center each month and to the appropriate medical staff departments or committees. Lack of timely documentation may result in suspension of the responsible physician or withholding of a physician’s paycheck until documentation is complete.
Research of Dictated History and Physical (H&P) Report
1. Using the previous day’s admission register, an HI specialist will check the dictation system and Meditech for a dictated H&P report on each patient.
2. If no dictation is found, the patient’s current in-house medical record will be checked to see if a handwritten H&P or an interim note is documented for patients readmitted within 30 days.
3. If a handwritten H&P or an interim note are not options acceptable per the Medical Staff Bylaws, Rules and Regulations and no other acceptable documentation is found, the name of the admitting physician will be documented on the attached form, and an HI specialist will flag the chart to alert the physician of the deficiency.
4. Names of physicians having delinquent H&Ps will be kept and statistics forwarded to the Process Improvement Center and to appropriate medical staff departments or committees on an ongoing basis. In addition, lack of timely H&P documentation may result in suspension of the responsible physician’s admitting privileges per the Medical Staff Rules and Regulations.
Research of Dictated Operative Report
1. Using the previous day’s reports not yet dictated list, an HI specialist will check the health system’s dictation system and Meditech for an operative report on each patient.
2. Search for the unit numbers for each patient on previous day’s “Surgery Schedule” by typing in the patient’s name.
• Write down the unit number in front of the patient’s name.
• Check to see if the report has been typed, if yes write down the “Trans” date and the initials of the MT.
• If no dictation is found, the dictation system will be checked.
• If no dictation is found from the dictation system, a call will be placed to the floor to inquire if an “interim note” (handwritten) is documented in the patient’s chart.
3. Names of physicians having delinquent operative reports will be kept and statistics forwarded to the Process Improvement Cen-ter and to appropriate medical staff departments or committees on an ongoing basis. In addition, lack of timely operative report documentation may result in suspension of the responsible surgeon’s surgical privileges per the Medical Staff Rules and Regulations.
Performance Improvement
Actions and Results
The HI staff understood the universal dislike of paperwork, charting in particular, by the physicians. However, they also understood the legal purposes and patient safety issues of concurrent documentation in the medical record, which include:
• To furnish other health care providers with information about the patient’s condition and the care already rendered.
• To protect the health care provider from the legal system should something adverse or unexpected happen to the patient.
In recent years, the medical record has attained tremendous stature, as a key element in most lawsuits brought against health care providers. Documentation encompasses many ethical and legal principles in which the physician must obtain. First and foremost, the ethical principle of veracity (truth telling) serves as the bedrock issue in documentation. Although veracity is an important element in all aspects of health care, it loses its ambiguity when it takes on a written form. Unfortunately, in documentation, there is no room at all for misinformation involving patient care. Not only is dishonest charting a violation of the ethical issue of veracity, but also a violation of the legal system. Charting activities that were not done, observations that were not made or vital signs that were not taken constitute fraud in the eyes of the legal system. Depending on the situation and the state where it occurred, fraud may be treated as a crime punishable by either a fine and/or jail term.
Another ethical principle that underlies charting is that of beneficence. To do good for the patient is a well-accepted principle in health care. A physician must believe that accurate, truthful, complete and timely charting aids in the cure of patients’ disease and hastens their recovery.
The process improvement initiatives of the HI department can serve as a model for any community hospital, tertiary care center, long-term care center, home health agency, outpatient center or physician office practice. The initiatives achieved in this department are far reaching, and each patient entering the hospital should have full assurance that the health information entered into the medical record will be timely, accurate and concise. n
Renee Mallet is the vice president of quality, Debbie Murphy is statistics manager, Sandra Mandich is coordinator and Ervanna Brugger is transcription coordinator, all for Licking Memorial Hospital, Newark, OH.
