With the advent of managed mental health services and its inherent financial controls there is always the risk that the quality of patient care will be compromised. The role of the provider as well as the payers, regulatory authorities and accreditation bodies is to assure that the cost controls and constraints on access and utilization do not adversely impact the quality of patient care.
Like cost containment, there are a variety of mechanisms employed to assure enrollees a minimum level of quality. One approach is to require that all providers and managed care organizations (MCOs) have accreditation through national standards bodies like JCAHO, CARF, COA, NCQA, etc. Each accreditation organization has its own standards and guidelines for quality.
Other standards for quality are described in the accreditation manuals of state and federal programs, and professional organizations catering to specific organizations, departments and functions in a healthcare facility, e.g. health information management (medical records). Since there is no one universal set of standards it is therefore up to the provider to develop their own quality assurance (QA) system.
"As defined by Berlant (1992) Quality Assurance refers to "activities designed to prevent and/or correct problems with quality. This implies altering the behavior of providers and practitioners. It may include screening for poor quality care, e.g. peer reviews, attempting to modify aberrant practice patterns, retrospective reviews of individual cases, chart audits of clinical performance, and various systematic monitoring and evaluation of specific treatment and charting practices."
In general, Quality Assurance systems include four areas including:
- Adherence to and assessment of clinical practices compared to standard rules and protocols
- Outcome of care - both individual cases and in aggregate
- Patient satisfaction
- Operational and procedural functions
Management information systems can play a major role in monitoring quality through the following functions:
- Medical records audits
- Major incident reporting
- Patient outcome monitoring
- Patient satisfaction measurements
As payers continue to ratchet down reimbursements there is the continued risk of compromising quality. QA systems can help improve an organization's operation both pro-actively and retrospectively. Obviously, the best way to correct a deficiency is to prevent it.
Therefore, a good QA system should produce tickler reports that list specific clinical and documentation activities including dates for completion, follow up review dates and case review schedules.
Another aspect of QA that a computer can help with is retrospectively checking the patient record. In automated clinical record systems the timeliness and completeness of entries to the record can be tested to assure that the required elements are present, and that they are appropriate to the case under consideration. Some applications can determine if the documentation was entered into the record in a timely manner. This is done by checking entry dates against required time limits calculated from the date of admission, date of service, date of last plan, etc. The computer, based on entries into the patient's record, can also select high risk or difficult cases. Alert flags and various clinical criteria can be tested, and records selected, for review.
Indicators of critical events or conditions can be searched for and the system can flag the record for a more detailed and intensive evaluation or peer review. Additionally, the QA record should have the ability to track and report results of audits/reviews, conclusions/analyses, recommendations for corrective action, results of actions taken and effectiveness. The system should also provide the ability to collect and monitor outcomes for individual cases as well as subgroups of treatment populations.
Patient and family satisfaction surveys can be digitally scanned and entered into a database for aggregate analysis and reports.
If your present system does not have a dedicated QA module or automated clinical record, you can still set up a simple documentation checklist for your QA staff. If all of the clinical documentation is not on-line, some systems will allow the user to create a simple checklist that records the results of a documentation review. Some sample items that could be recorded relevant to a patient's clinical documentation include the following:
- Service date
- Service note date
- Is the note linked to a specific service?
- Is service linked to a treatment plan goal?
- Is the service authorized?
- Is the service consistent with the recommended treatment protocol for that diagnosis and presenting problem?
- Treatment plan - date due and completed
- Treatment plan update or quarterly report - dates due and completed
- Discharge plan - dates due and completed
- Presence of required signatures on various documents
- Presence and date of required consents and releases
Admission:
- Referral form (y/n): ___
- Consent for Treatment forms (y/n): ___
- Release of Information forms (y/n): ___
- Billing Information (y/n): ___
- Emergency Contact forms (y/n): ___
Assessments:
Please indicate which of the information was documented in the intake assessment:
- Presenting problem (y/n): ___
- Mental status (y/n): ___
- Rule out diagnosis (y/n): ___
- Previous mental illness (y/n): ___
- Substance abuse (y/n): ___
- Total deficiencies: ___
Psychosocial history:
Please indicate which of the information was documented in the psychosocial history:
- Interpersonal relationships (y/n): ___
- Medical History and Drug Profile (y/n): ___
- Education (y/n): ___
- History of mental illness in family (y/n): ___
- Completed within X days of admission (y/n): ___
- Total deficiencies: ___
Individual Plan of Service:
Please indicate which of the information was documented in the IPOS:
- IPOS indicated a problem, with related goals and objectives (y/n): ___
- IPOS indicated specific interventions (y/n): ___
- IPOS indicated specific staff (y/n): ___
- IPOS indicated discharge criteria (y/n): ___
- IPOS was reviewed every X months (y/n): ___
- Total deficiencies: ___
Progress Notes:
Please indicate which of the information was documented in the progress notes:
- Progress notes are documented for each service (y/n): ___
- Notes relate back to treatment goals (y/n): ___
- Notes document the patients response to treatment (y/n): ___
- Total deficiencies: ___
Discharge Summary:
Please indicate which of the information was documented in the discharge summary:
- A discharge summary was prepared within X days of termination (y/n): ___
- The discharge summary included the level of functioning (y/n): ___
- The discharge summary included the diagnosis (y/n): ___
- The discharge summary included the reason for discharge (y/n): ___
- The discharge summary included the service summary (y/n): ___
- The discharge summary included any referrals (y/n): ___
- The discharge summary included medication instructions (y/n): ___
- Total deficiencies: ___
- Grand total of all deficiencies: ___
Since the results of a manual review are not derived automatically from the system, the user has several options to partially automate the process. The QA survey can be kept in the central MIS or on a stand alone PC in a database, spreadsheet or statistical package. Obviously this is not the ideal method of automating the QA process but it does provide clinical records with an on-line record of the review.
These data can then be correlated with other program, staff and patient related variables. Regardless of the method used to automate your QA functions, it is a distinct advantage to automate as many of the clinical charting and records management functions as possible. Obviously, the more information available in the system, the greater the number of documents and activities that can be checked automatically (Johnson 1996b in Stout).
In summary, information systems can play an important role in the implementation of a QA system. The key to developing a fully automated QA system is to automate as much of your clinical records as possible. The QA reports can be run against the electronic record to identify deficiencies, inconsistencies and other problems that might be used to trigger a detailed audit. Quality data from other components of the record that are not automated can at least be recorded on the system for future reference and reporting.
About The Authors:
Bruce Johnson, M.S., is President of Johnson Consulting Services, Inc., an information management consulting firm that specializes in working with healthcare, social service and managed care organizations. He can be reached at (800) 988-0934, www.jcsconsultants.com or by e-mail at jcsinc@fuse.net. Mr. Schafer is a clinical records and operations management consultant. He specializes in working with managed care, behvavioral healthcare and child welfare organizations. He can be reached at (800) 661-2435, www.schaferconsulting.com or by e-mail at steve@schaferconsulting.com.
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