Quality Assurance / Quality Assurance Performance

Improvement & Monitoring For The Health Information

Management/Record Department

February 12, 2014 (Bakersfield, CA)

February 13, 2014 (San Jose, CA)

February 14, 2014 (Riverside, CA)

OBJECTIVES

Participants will identify the key management principles for: Managing the HIM/Record Department Assuring a HIM/Record Department Evaluation is

followed up

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OBJECTIVES -2

Participants will: Identify those QA processes that are used as a

guiding principal for managing the facility Specifically review the QA process as it relates to

managing audits Develop a plan for your own audit process and

follow up action plan Will identify the ADM, MRD and HIM/Record

Consultant action/follow up

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QI GOAL

Identify systems breakdown in audit process and develop and monitor interventions

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QA PROCESS

Review of the QA Process Identify areas of concern/continuous quality

improvement processes, set out the goals, identify the criteria, collect data, identify measurement, evaluate and assess the information, analyze the causative factors, develop action plans and follow up – recycle!!

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QA

Responsible for the overall direction of the facility’s quality improvement functions through a quality assessment/improvement program/plan

Will spend more time on this in future workshops

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QUICK MANUAL REVIEW

Let’s look at the manual Table of ContentsKey focus areas today

QA audits and monitoring Audit tools HIM Dept Evaluation (H.O. #1)

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HIM / RECORD DEPARTMENT ORGANIZATION

Review of the HIM/Record Department organization and expectations

HIM/Record Department Evaluation (H.O. #1)1. Location of Items in the HIM/Record Dept.

2. The Basics of organization

3. Auditing and monitoring policy/schedule/organization/follow-up – QA reports

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ORGANIZATION OF HIM / RECORD DEPT.

Review the Organization of the HIM/Record Dept (refer to HIM #4005)

Identify those Health Information Department items for improvement and documentation items from the HIM/Record Consultant

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ORGANIZATION OF HIM / RECORD DEPT. -2

PRACTICE Determine for your facility those areas that need

improvement. List them from your knowledge. Reconcile for all the facilities

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TOP 20 DEFICIENCIES & FOCUSED AUDITS

Top 20 Deficiencies (H.O. #2) #1 Quality of Care – Identify those audits

that would measure documentation, i.e., behavior drugs, falls, restraints, pain, etc.

#2 Care Plans – Identify where the most deficiency is applicable to your facility; at C of Condition, after IT Team Quarterly Reviews with the MDS resulting in update of CP

#3 Pharmacy Procedures – results from the new pharmacy survey, RECAPS, med/tx. Documentation, etc.

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TOP 20 DEFICIENCIES & FOCUSED AUDITS -2

Measure against Unnecessary Drugs – Pharmacy QI include in QA process (refer to HIM #7050 Behavior Drugs Monitors Antipsychotic (H.O. #3.1) Non-Antipsychotic (H.O. #3.2)

Complete Records – Discharge Summary to be reviewed later

Note: Reference only – cover during audit discussion

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WHY PLAN FOR AUDITS AS PART OF QA?

In order to ensure that the documentation of the quality of care and services provided to all residents meets the needs of the residents and reflects high quality outcome of services and care process

Documentation supports those services and we can document the quality of services.

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QA PROCESS

Identifies and addresses quality issues; including documentation items.

Provides a tool to coordinates the qualitative documentation activities of all departments.

Establishes assessment and improvement priorities for audits and follow up.

Sets expected outcomes for documentation o0f resident care, services and related administrative services;

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QA AUDITS AND MONITORING

REVIEW of the Medical Records Compliance Audit – this is the “standard” (H.O. #4)

Let’s agree on a standard. (Get input from the facilities).

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QA - PLANNING

Identify those standard audits that need to be carried out

Identify the LifeHouse priorities – the rating of where LifeHouse stands against those CMS identified areas where improvement is needed

Determine which audits will apply to your facility

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COLLECT INFORMATION

Establish the Medical Record Director’s schedule for auditing

Standard Audits – those are the required audits as set by LifeHouse

Review and determine agreement on the Medical Records Compliance Audit (H.O. #4)

Determine the required without exception – identify those audits/monitoring

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ADMISSION MONITOR

Let’s walk the Admit audit process Admission Monitor (H.O. #5.1) Admission 7-14-21-30 Day Combined Monitor

(H.O. #5.2) Admission JCAHO Subacute Monitor (H.O. #5.3)

Note: We may change to a Discharge from Medicare and at discharge

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ADMISSION MONITOR -2

PRACTICE Discussion Q&A from last 5 admit audits Identify out of the 3 audit items best meet your

needs and AHIS will reconcile

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DAILY QUALITY ASSURANCE REVIEW SYSTEM – CHANGE OF CONDITION

Used to identify problems, concerns and conditions where additional follow up, review or referral are needed or desired

A method of continuous quality care outcome review

Action/results oriented

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SYSTEM BENEFITS

Reduces duplication of efforts Follow up tasks identified and assigned to staff on

specified due datesFocus on

Timely identification of deficiencies/problems Prevention of repeat deficiencies/problems Continued review of follow through until resolution

so that nothing “falls through the cracks”

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SYSTEM BENEFITS -2

Utilizes time spent in daily stand up meeting to maximize results – quality outcomes

Promotes ID team involvement in problem identification and problem solving

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SYSTEM COMPONENTS

24 hour report/shift report Incident reportsChange of condition monitorReports of resident/family

concerns/complaintsDaily quality assurance review form (log)Daily standup meeting

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24 HOUR REPORT

Centralizes nursing communications on a shift by shift basis

Helps to ensure timely follow up from shift to shift or day to day

Usually the first documented indication of a new or impending problem or change of condition

An important link in the audit trail Important source of information for the IDT as

well as nursing 24

INCIDENT REPORTS

Another important link in the audit trail

Provides detailed information that must be carefully documented, reviewed and trended

Must be integrated into the QA process ongoing

Daily review of reports to ensure quality outcomes and timely follow up 25

CHANGE OF CONDITION MONITOR

Reviews information given in the 24 hour report, incident reports and telephone orders

Identifies changes and problems requiring follow up in the last 24 hours (or 72 hrs. over the weekend)

Centralizes and identifies changes and any deficiencies or “loose ends” in documentation

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RESIDENT/FAMILY CONCERNS AND COMPLAINTS

Frequently not picked up and processed in a methodical manner

An important source of information about the resident, impending or actual problems and changes of condition

Need to be identified and addressed by the IDT in a timely manner

IDT involvement and reporting is critical

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CHANGE OF CONDITION MONITOR -2

Complete daily prior to the standup meetingReview 24 hour report, incident reports and

telephone orders that denote a change of condition

List all changes of condition on the monitor form

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WHAT MAY INDICATE A CHANGE OF CONDITION?

Changes can be physical, mental or psychosocial

Change can Be slow to develop and show

subtle signs or Develop rapidly with more obvious

signs and symptoms

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WHAT MAY INDICATE A CHANGE OF CONDITION? -2

When reviewing the 24 hr. report look for Reports to nursing by family, C.N.A.’S, R.N.A.’S,

ancillary services that something has occurred or is changing in the resident’s condition

Don’t overlook resident/family complaints

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WHAT MAY INDICATE A CHANGE OF CONDITION? -3

New orders for: An antibiotic Treatment Physical or chemical restraint New support or assistive device Weight loss or gain X-rays and labs

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WHAT MAY INDICATE A CHANGE OF CONDITION? -4

Changes in orders can also indicate a change of condition. For example: Increase in dose of psychotropic medication A change from one type of physical restraint to

another type A change in type of assistive device used to treat a

condition or maintain mobility Change in treatment order because the site is not

responding

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WHAT MAY INDICATE A CHANGE OF CONDITION? -5

When reviewing incident reports look for: Falls Medication errors Injuries/death resulting from defective equipment Resident to resident or resident to staff altercations

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COMPLETING THE COC MONITOR

Look at the audit form (H.O. #6) – reference HIM #7050

Review the Legend at the bottom of the form These are the codes used to complete the form

Review the Incidents and Accidents box These are some general related guidelines

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COMPLETING THE COC MONITOR -2

PRACTICE Review of the last 3 change of condition monitors

from each facility in your group Summarize issues Plan for facility and Corporate-wide

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STANDARD AUDITS

Change of Condition – dailyWeekly skin report (done by the treatment

nurse and audited by the MRD for qualitative documentation). (HIM/Record Consultant may need to assist with the quality training.)

Quantitative Reviews – Is it or isn’t it there?Clinical Record Monitor (reference HIM

#7050)

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STANDARD AUDITS -2

Weight audit – (may be done by others)Admission AuditDischarge AuditsPsychotherapeutic drugsSpecialized monitoring, i.e., review H.O. #4

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AUDITS AND THE FOLLOW UP

Audit schedule with required audits and QA reporting and schedule

Audit/Monitor Schedule on the Administrator’s and DNS desk; follow up to assure MRD audits carried out as planned.

HIM/Record Consultants assists with above and provides training and monitoring to assist with the quality of the process 38

MEDICAL RECORDS AUDIT SCHEDULE

H.O. #7Monitored by HIM/Record Consultant

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DISCHARGE SUMMARY REQUIREMENTS

Review HIM Policies/Procedures Discharge Chart Monitor (HIM #3520) Order of Filing – Shortened Discharge Chart (HIM

#3506) Inhouse Order of Filing (HIM #4035)

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GENERAL DOCUMENTATION REQUIREMENTS

Willful Omission and Willful Falsification of Records….”AVOID THE RISKS”

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OBJECTIVES

Participants will Identify the correct method to document, timely,

accurately Identify what is willful falsification and willful

omission Recognize documentation correction issues

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GENERAL DOCUMENTATION GUIDELINES

Every entry is recorded promptly after the care/tx is given, i.e., for medications/treatments the documentation is done at the time of the med/tx

Food intake, at the end of the meal Intake and output – at the time of measure of

the intake and the output

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ENTRIES

Complete, concise, accurate!! Made by the person carrying out the care/tx

(not by another person for someone else) Chronological

Used abbreviations only if approved by the facility and in the manuals

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ENTRIES -2

In black or dark blue ink or typewritten – e-record

Must be capable of being copiedMust be legibleHighlighters may cause obliteration

when copied – recommend against use Include date, month, year and time (if

appl.)Signed by appropriate person with

professional title, i.e., C.N.A., R.N., L.V.N.

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EXERCISES

Are there situations when documentation is carried out late?

A fellow staff member tells you they observed Mrs. Jones (the fellow staff members resident) sitting and falling to one side and she wasn’t sure what was wrong but informed the nurse. Please document that in the record. What should be done?

When documenting is it necessary to include position title, i.e., C.N.A., R.N., L.V.N., etc.?

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DO NOT!!

Use white out, write over an entry,black out an entry

Sign for another person Copy records or completing any portion of a

record without your personal knowledge the care was given, the data is accurate. Otherwise this could be construed as “falsification of records”

Leave blank spaces Document before an entry occurs

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EXERCISES

Falsification of records may be interpreted in the following situations.1. White out is used and then someone wrote over the white out. Is this allowed for legal documentation?

2. It is o.k. to leave a blank line between your note and the last note written?

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EXERCISES

Now that we have computer documentation, order entry in your situation – and the med/tx records are printed there is no way to have a record that is incomplete or not accurate? What could be a question??

If you do not have time you can leave the space for charting until the next day. Is that correct?

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CORRECTION Records may be corrected by drawing

one line through the error, designate error, initial the error and chart the correct information with date and time if applicable.

Computer system – each system has a method of correcting the documentation and ability to track. Follow the guide.

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WILLFUL FALSIFICATION

Entries in the record shall be factual Accurately reflect the services provided to the

resident Accurately reflect the condition of the

resident, Accurately reflect the resident’s response to

treatment and services

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ALERT TO ACCURATE CHARTING

All staff shall be aware that an entry in the record that is made with the knowledge that the record falsely reflected the condition or situation is “willful material falsification”

Subject to civil penalty and $$…personally can be assigned to the employee

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WILLFUL OMISSION

If staff are aware of any untoward event that affects the resident, and not documenting that information correctly, therefore causes the record to falsely reflect the condition of the resident, or the care or services provided shall be considered to be a “willful material omission”

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EXERCISE

A staff member observed the resident and found the resident on the floor. The person did not know what happened, however documented that the resident had sat down on the floor and did not seem to be in any distress. The resident was complaining of pain. The fact was that the resident was found on the floor, the resident was complaining of pain and this was reported to the nurse, but did not include a note. Is this willful falsification or willful omission?

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WHAT TO DO ABOUT AUDITS!!

Correction or late entries are possible but care needs to be taken between falsification and accurate correction.

Practice Examples: Q & A

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AHIS CONTACTS

Elizabeth Rumbin, RHIT, HI Consultant

smrumbin@aol.com or 805-895-4517

Khaleelah Wagner, RHIA, HI Consultant

khaleelahwagner@hotmail.com or 909-717-7102

Staci LePage, RHIT, HI Consultant

stacilepage@comcast.net or 916-202-5797

Rhonda Anderson, RHIA, President

rhonda@ahis.net or 714-299-0573

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THANK YOU FOR ATTENDING!!

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