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QA Best Practices. QA Best Practices Tool Kit Task Force. The Back Story. QA Summit. Locating QA Best Practices Info. Healthcare Documentation Quality Assessment and Management Best Practices – July 2010. Dissecting the Document. Principles of Quality Factors Affecting Quality Personnel
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QA Best Practices QA Best Practices Tool Kit Task Force
The Back Story • QA Summit The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
Locating QA Best Practices Info The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
Healthcare Documentation Quality Assessment and Management Best Practices – July 2010 The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
Dissecting the Document • Principles of Quality • Factors Affecting Quality • Personnel • Assessment Policies and Procedures • Sampling Guidelines • Error Categories, Definitions, Scoring • Continuous Quality Improvement • Recommendations The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
PDCA (Shewhart Cycle or Deming Circle) • PLAN • DO • CHECK • ACT The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
Principles of Quality • Verifiability • Definability • Measurability • Consistency • Integrity The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
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 The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
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 The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
Factors Affecting Quality • The Author • Experience • Equipment • Patient Demographics • Account Specifications • Resources The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
BLANKS ___ • VALID • INVALID The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
Personnel • The Quality Players - Medical Transcriptionists - QA Editors / Supervisors / Managers - Support Staff / IT - Healthcare Providers - Administration / HR - Trainers / Instructors - Educational Institutions The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
QA Guidelines • Policies and Procedures - Concurrent Review - Retrospective Review - Flagged Documents - Feedback - Author Assessment The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
Sampling Guidelines • Statistically Valid Sampling - Random - Sample Size 1% per month recommended 95% confidence level 0.851 margin of error The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
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 The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
Critical Errors • Terminology Misuse • Omissions/Insertions • Incorrect Patient Demographics or Author Identification The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
Noncritical Errors • Misspelling • Incorrect Verbiage • Failure to Flag • Protocol Failure • Formatting/Account Specifications The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
Feedback Errors / Educational Opportunities • Grammar • Punctuation • Capitalization • Plurals • Run-on/fragment sentences • Abbreviations • Slang • Inconsequential typos and omissions • Incorrect word forms The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
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 The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
Continuous Quality Improvement Process The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
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 The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
Steps to Implementation • Importance of Adopting QA Best Practices • Getting Started • Making the Transition • Transition Tools The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
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. The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
Getting Started • Evaluate current system • Work to overcome barriers • Encourage a cultural shift • Explain scoring methodology and rationale The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
Transition Techniques and Tools • “Why the Changes” Handout • Adoption Guide • Checklists • Scoring Spreadsheet • Scoring Spreadsheet Video The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
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! The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
QUESTIONS? The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
THANK YOU! The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit