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Transcript of QA Best Practices Tool Kit Task Force The Back Story QA Summit The Healthcare Documentation Quality...
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QA Best Practices Tool Kit Task Force
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The Back Story QA Summit
The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
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Locating QA Best Practices Info
The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
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Healthcare Documentation Quality Assessment and Management
Best Practices – July 2010
The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
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Dissecting the Document Principles of QualityFactors Affecting QualityPersonnelAssessment Policies and ProceduresSampling GuidelinesError Categories, Definitions, ScoringContinuous Quality Improvement Recommendations
The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
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PDCA (Shewhart Cycle or Deming Circle)PLANDOCHECKACT
The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
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Principles of Quality Verifiability DefinabilityMeasurabilityConsistencyIntegrity
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Quality Assurance GuidelinesAccurate and complete medical recordsTimely and accessible distributionStatistically valid samplingAuditing applied to all documents, however
createdConsistent unbiased reviewError values consistent with definitions hereinConsistent communication regarding errorsAvailability of reference materials and
account specificationsThe Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit
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Comprehensive Quality Assurance ProgramsProactiveEducationalRealistic, scalable, and financially feasibleSimple and easy to implementSecure and confidentialInclusive of all aspects of the author-to-text
processReportable for tracking and trending purposesTimely
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Factors Affecting Quality
The Author ExperienceEquipmentPatient DemographicsAccount SpecificationsResources
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BLANKS ___VALID INVALID
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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
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QA GuidelinesPolicies and Procedures
- Concurrent Review- Retrospective Review- Flagged Documents- Feedback - Author Assessment
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Sampling GuidelinesStatistically Valid Sampling
- Random- Sample Size
1% per month recommended95% confidence level0.851 margin of error
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Error CategoriesCritical 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
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Critical Errors
Terminology MisuseOmissions/InsertionsIncorrect Patient Demographics or Author Identification
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Noncritical Errors
MisspellingIncorrect VerbiageFailure to FlagProtocol FailureFormatting/Account Specifications
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Feedback Errors / Educational OpportunitiesGrammarPunctuationCapitalizationPluralsRun-on/fragment sentencesAbbreviationsSlangInconsequential typos and omissionsIncorrect word forms
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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
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Continuous Quality Improvement Process
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Quality Improvement StrategiesSet quality assessment intervals
Monthly, quarterly, semiannually, or annuallyCustomize to individualAddress system wide problems
Areas to be addressedTechnical systemsAuthor issues (See also Dictation Best Practices
Tool Kit)Account specificationsMT concerns
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Steps to ImplementationImportance of Adopting QA Best PracticesGetting StartedMaking the Transition Transition Tools
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Importance of Adoption• Changing world
EHR Cost reduction
• Need for new best practicesWork 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.
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Getting Started
Evaluate current system Work to overcome barriers Encourage a cultural shift Explain scoring methodology and rationale
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Transition Techniques and Tools
“Why the Changes” HandoutAdoption GuideChecklistsScoring SpreadsheetScoring Spreadsheet Video
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Recommendations Apply principles of qualityAssess factors affecting quality Establish clear policies and proceduresDevelop a feedback mechanismProvide training and mentoringFollow a quality assessment schedule Compile, track, and analyze QA data
Remember – PDCA!
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QUESTIONS?
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THANK YOU!
The Healthcare Documentation Quality Assessment and Management Best Practices Tool Kit