QA Best Practices

1. QA Best Practices QA Best Practices Tool Kit Task Force

2. The Back Story • QA Summit The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

3. Locating QA Best Practices Info The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

4. Healthcare Documentation Quality Assessment and Management Best Practices – July 2010 The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

5. 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

6. PDCA (Shewhart Cycle or Deming Circle) • PLAN • DO • CHECK • ACT The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

7. Principles of Quality • Verifiability • Definability • Measurability • Consistency • Integrity The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

8. 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

9. 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

10. Factors Affecting Quality • The Author • Experience • Equipment • Patient Demographics • Account Specifications • Resources The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

11. BLANKS ___ • VALID • INVALID The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

12. 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

13. 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

14. 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

15. 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

16. Critical Errors • Terminology Misuse • Omissions/Insertions • Incorrect Patient Demographics or Author Identification The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

17. Noncritical Errors • Misspelling • Incorrect Verbiage • Failure to Flag • Protocol Failure • Formatting/Account Specifications The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

18. 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

19. 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

20. Continuous Quality Improvement Process The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. QUESTIONS? The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit

28. THANK YOU! The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit