REAL QA for Medical Transcription

I am reminded once again about my frustration with the "quality assurance" process we find in the medical transcription industry, and I have suggested the inappropriate manner in which we do this to the ends of the earth.  In a recent online discussion I had with Jay Vance, (President, AHDI), Jay mentions to me that he may understand my frustration with my inability to get the point of my vision across to the medical transcription industry at large.  I can only take this as my own responsibility as a place from which to speak; that is, if I blame, there is no power in that position.  But, I will be gentle on myself as the brick walls in this industry are thick and tall.

I digress.

In the clinical setting, ALL inpatient admissions are reviewed against a set of criteria like this -
- Unexpected return to the OR- Unexpected transfer to higher level of care
- Infection
- Iatrogenic injury
- Readmission within 24 hours
- Blood transfusion (all blood is reviewed against objective criteria)
- Surgical indication (all surgeries are reviewed against surgical indication criteria)
- Intraoperative complication
- Discharged AMA

There are more, and hospitals can add their own, maybe they are doing a focused study, for instance.

Each hospital will have a process for reviewing these.  Usually it is done concurrently, while the patient is in the hospital, and then the review continued through until discharge.  The concurrent review allows for the ability to intervene in the patient's care in an effort for improvement.  For instance, if an infection is identified, this might be a way to alert the infection control nurse to follow.  These processes can be generic in nature (such as my list) and they can be customized to accommodate, again, a focused concern identified by a particular department.  The information from these review sheets will be entered into an electronic database for the purpose of providing cumulative data and for identification of cases for peer review.  It is key to understand that this is done on ALL patients on an ongoing basis.  "On an ongoing basis" is key to identifying trends.  All cases and ongoing are two things that the medical transcription industry does not do.  Because of that, we do not have the opportunity to truly identify trends, truly get a big picture, truly identify root causes, truly identify knowledge versus typographical errors, truly provide feedback that is meaningful and effective.

Using the clinical review methodology above as an example, we could use something like this to perform something similar for the medical transcription industry.  I would suggest assigning staff for the purpose of QA, collecting this information, entering the information into a database, proofreading, correcting the reports.  It would be done on ALL reports.  If you don't think there is enough time, imagine how much time can be saved by correcting MD behavior (OH YES, it is very possible), properly educating MTs, fixing audio problems, all of the time we spend on these issues stumbling over the top of them for decades now.  Imagine the value of using proper proofreading, not to scold the MT, but to add an additional layer of quality to the very important reports that we transcribe.

Using that data entered, now you can sort the data by dictator, MT, type of problem, dates, work types, etc.  The data entered, is always available, can be used to truly demonstrate MT and MD improvement.  Send an MT a singular report showing that he/she transcribed phosphorus instead of phosphorous?  Meh.  Send an MT a trend report that shows that is consistently done?  Now you have an opportunity to correct human errors.  Call an MD and tell him his dictations are difficult?  Meh.  Send an MD a report showing that 90% of his reports are difficult, that the MT has to leave 5 blanks on average, that the QA reviewer can only correct half of those?  Now you have some data.  If the doctor wants to ignore that?  Now you have data for his boss, the chief of staff, the executive committee, and board.

Here's an example of a type of worksheet medical transcriptionist departments might use.  Of course, you could add many other elements to the abstract.  This is an example.

 

qa report abstract snipped revised

I know many will immediately say, "We don't have the time or budget for this type of review."  We can't afford NOT to be doing this and once the process gets under way, we'll be correctly identifying and solving so many problems, identifying root causes (the doctor should be accountable for an intelligible report, not the MT for figuring it out), correcting errors before the report is finalized, providing a means to correct errors found later.  This is true quality assurance, the type of review The Joint Commission advocates, the type of review that will enforce true management of the reports we create.

In the coming weeks, I'll be creating some mock reports that mimic the type of reporting mechanisms for clinical quality management to demonstrate my proposed process.

5 Comments

  1. Debbie - January 19, 2016, 9:35 am

    No, Jay! I took your comments to heart, not a negative. I appreciated them. I also agree that AHDI has done some great work with tool kits and such. Here is where we depart, it seems. There feels to me an over-reaching political correctness within the organization movements that I find VERY frustrating, while a blood bath is going on in our industry, not standing up tall, loud, and firm to get after these issues and going to the right organization (in my mind, The Joint Commission). To me, that is huge. And, when we get a “no,” that doesn’t mean end of story. We have to keep at it, and my poverty financial state, and I’m not exaggerating, can’t manage that without more support. Second, while I have seen such similar ideas promoted by AHDI, here is what is not appreciated, in my mind. Quality management must take place in a comprehensive manner, it must attribute issues to the accountable party (MTs should not be figuring out bad dictation; doctors should be counseled to improve their speaking or use another device, or move out of the lithotripter room), it must be ongoing, it must identify trends. A similar worksheet that gets done on 5 random reports for an MT, doesn’t involve an analysis of the dictator, the audio quality, and isn’t providing the entire picture of what is going on and is missing the point. You want to be able to collect that data and then be able to enter it into a database so you can retrieve it by MT, MD, work type, month, day of the week, and THEN, use the raw data to identify statements of problems. You want it collected over time so you can view it to identify improvements, you want to do it on ALL reports. As I mentioned, I will work on the next steps and show that. I have worked for a LOT of organizations by now so I know I speak confidently to say what I am proposing happens nowhere. So, yes, we may agree on a type of tool listing issues, but this industry is fixated on MT errors and uses it in that manner. We want to be able to really and truly be able to identify the root cause, track and trend them, report and improve. That is not happening in this industry.

  2. Jay Vance - January 18, 2016, 11:56 am

    Debbie, I think it’s extremely significant that two of the three previous comments were both along the lines of “Now I see what you’ve been talking about.” I share that same sentiment. I think with this post you’ve done an excellent job of “tangibilizing” (I love making up new words!) the concepts you’ve been describing in more or less abstract terms up to this point. With this post, the abstract becomes much more concrete and, well, tangible. I don’t think anyone who cares about the plight of the working MT/HDS or about quality in clinical documentation or about improving healthcare in general could argue with the validity of your reasoning. Kudos on a great article!

    Of course, it will come as no surprise when I point out that AHDI has been advocating for some time for many of the elements in your recommendations. As I’ve commented to you previously in various public or private conversations, I honestly don’t believe you and AHDI are pursuing conflicting goals. What I think is evident as a result of this article is that your vision is much broader and all-encompassing than the approach AHDI has taken, and it may very well be that it would be appropriate for AHDI to consider the feasibility of adopting a broader scope when setting our strategic goals and outcomes. Naturally, as you and I have also discussed previously, that sort of change doesn’t happen quickly in a membership organization by virtue of the way associations are structured and governed. But please don’t think that your ideas are being ignored or dismissed out of hand within AHDI circles. I assure you that’s not the case. We may not always (or ever) agree 100% on things like how to best approach and engage with entities such as TJC, but I think in general we all want the same things.

    Finally, I did want to clarify any comments I made to you regarding the difficulty of getting your vision across to the medical transcription industry at large. I can assure you that in no way was that meant as a criticism of you or your vision. I believe what I said was that historically it has been a challenge to unite practitioners in our field behind ANY cause, regardless of who is promoting it. I don’t know why that is; I’ve heard a variety of opinions on that topic. But for whatever reason, creating consensus among MTs/HDSs has always been challenging, and I would certainly never criticize you for struggling with the same sticky wicket many others before you have encountered. But neither would I ever try to discourage you from continuing to fight the good fight in the way you feel is best.

  3. Pia Desselle - January 16, 2016, 2:44 am

    Now I see where you’re coming from with this example.

  4. Debbie - January 15, 2016, 5:25 pm

    Thank you, Cindy!! Thank you for your never-ending support 🙂

  5. Cindy A. - January 15, 2016, 11:27 am

    Fabulous example! It makes so much more sense seeing it in these terms! You would be a much needed person on the JC team to develop and establish this! Thank you for your vision!

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