1. Quality Assurance (QA) for Clinician-Created Documentation

2. The Need for Quality Assurance
Patient safety can be compromised
Incomplete or inaccurate documentation
Lost revenue
* In considering these potential negative consequences, the upfront expense of a QA program outweighs the far-reaching and long-term impacts of forgoing a QA Program.
Patient safety can be compromised by incomplete or inaccurate documentation.
Incomplete or inaccurate documentation will have a negative impact on coding and billing functions.
Lost revenue to the facility or overpayments impact the facility’s bottom line.
Damaged reputations (physician, facility, patient, etc.), accusations of malpractice, subsequent costly litigation, and even criminal penalties if billings are found consistently erroneous that they are considered fraudulent.

3. The Need for Quality Assurance
A Quality Assurance (QA) program
is not
A Clinical Documentation Improvement (CDI) program QA
CDI
A quality assurance review ensures quality and documentation integrity.
CDI professionals review documentation for “any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care,” according to AHIMA.

4. The Need for Quality Assurance
A CDI program facilitates the accurate representation of a patient’s clinical status that translates into coded data.1
A QA program is the COMPLETE REVIEW of the narrative and demographic data to protect the patient, caregiver(s), and the organization’s documentation integrity.
CDI Program:
Appropriate severity of illness
Expected risk of mortality
Expected complexity of care
QA Program:
Protect patients
Protect caregiver(s)
Protect organizational integrity
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5. The Need for Quality Assurance
Organizations should incorporate BOTH programs to ensure documentation integrity and regulatory compliance throughout the healthcare continuum. QA
CDI

6. The Need for Quality Assurance
Risks of Unmonitored EHR Documentation Practices
Patient Safety
Financial Impact
Compliance Issues
Legal Consequences
Patient Safety:
Compromised patient safety
Patient dissatisfaction/lack of trust
Duplication of effort and expense
Financial Impact:
Delays in revenue cycle
Inadequate reimbursement
Increased cost of error resolution across information systems
Compliance Issues:
The Joint Commission reports that 52% of their accredited organization and certified programs were not compliant with standard RC , which is “The hospital maintains complete and accurate medical records for each individual patient.”
Legal consequences:
Fraud citations
Compromised organizational reputation
Unreliable/invalid reporting and analytics

7. The Need for Quality Assurance
Common EHR Practices that Create Vulnerabilities
Copy and paste or “note bloat”
Lack of review, correction, and feedback
3. Unmanaged/inconsistent template creation and modification leading to automation errors
4. System(s) designed and built with limited healthcare documentation expertise
#3 can also include the use of macros, expanders, or different automation techniques.
A QA program can effectively address each of these issues to ensure quality of care and continuity of care, and to decrease physician and clinician frustration while streamlining and supporting the documentation process.
Reference “AHIMA Copy and Paste Position Statement” link in Resources slide at the end of the presentation

8. The Need for Quality Assurance
Additional vulnerabilities:
Inappropriate abbreviations
Inappropriate templates
Wrong patient/wrong visit
Selecting incorrect check boxes
Speech “wrecks”
Don’ts
Not using standard abbreviations
Use of the wrong visit type, or wrong dropdown in the EHR forms
Cut and Paste as a shortcut, leading to mistakes and misinformation
Speech “Wrecks”: systems that misinterpret what the originator is saying or overlooked front-end speech recognition misrecognitions
Insertion of inconsistent or lengthy progress notes or pre-completed notes
Dos
Support the standard of care
Avoid inaccurate, outdated, or redundant information
Avoid propagation of false information or typos
Verify patient demographics information, medications, dosages, etc.

9. The Need for Quality Assurance
Best practices should be used to protect the integrity of the patient’s health information.
The HEART of the matter = PATIENT SAFETY
Fraud is not the only concern.

10. CLINICAL DOCUMENTATION
Complete and accurate documentation reduces errors, improves management, and ensures appropriate funding.
ACCURATE
CLINICAL DOCUMENTATION
Fewer Medication Errors
Appropriate medical care
Continuity of care
Improved Management
System errors detected
Accurate data abstracted and submitted
Appropriate funding
Equitable resource allocation
Improved regional planning

11. Workforce and Skill sets
The healthcare professionals behind quality assurance programs
Workforce and Skill sets
To Presenter: The following slides can be used if applicable to the situation. They can help explain who is behind the QA process and the importance of their skill sets.

12. The Role of the Healthcare Documentation Specialist (HDS)
Produces documentation that reflects the patient’s story in a correct, complete, and consistent manner
Ensures accurate documentation
Creates a business record that can be trusted and referenced
Correct, complete, and consistent.
Represents the decision-making process, intentions and actions of the caregiver, as well as the course of treatment, choices, and outcomes of the patient.
3. For future research, decision making, and legal/compliance justification.

13. The Role of the Healthcare Documentation Specialist (HDS)
Reviews healthcare documentation content and provides feedback to clinician
Develops and maintains template design program
Trains clinicians on template usage
Collaborates with key stakeholders
Includes the patient in documentation process whenever deemed possible
Strives for continuous quality improvement
Reviews content generated by speech recognition to QA
Develops and maintains a template design program
Trains clinicians on proper template use
Collaborates with HIM, HIT, HDSs, and other key stakeholders
Includes the patient in the documentation process whenever deemed possible
Strives for continuous quality improvement, establishes and implements the feedback process

14. The Role of the Healthcare Documentation Specialist (HDS)
Reviews and flags documentation
Validates patient and visit demographics
Flags critical errors for correction
Identifies minor errors
Provides feedback to the originating clinician
Content review assists with coding and reimbursement and template creation
Review, flag, and/or correct documentation
Validate patient and visit demographics
Review for and flagging critical errors
Identify and correct minor errors
Provide and request feedback from the originating physician/clinician
A. Safety net (“second set of eyes”) for the clinician and the patient
B. Educational opportunity for the reviewer
3. Content review assists with coding and reimbursement and template creation

15. AHDI-AHIMA Clinician-Created Documentation Resource Kit
Error Categories
Dashboards and Trending/Tracking Spreadsheets
Best practices, Examples, and Templates
QA Review Form Template and Sample
QA Program Checklist
QA Program Sample Policies/Procedures
Model Job Descriptions
Documentation Review Forms and Samples
Video Tutorial

16. Resources AHDI-AHIMA Clinician-Created Documentation Resource Kit
A Guide to Better Physician Documentation
AHDI/MTIA/AHIMA Healthcare Documentation Quality Assessment and Management Best Practices
AHIMA Copy and Paste Position Statement
Dimick, Chris. "Documentation Bad Habits: Shortcuts in Electronic Records Pose Risk." Journal of AHIMA 79, no.6 (June 2008):
The Joint Commission - Most Challenging Requirements in 2013