Quality  Assessment  Project  Linda  Cheung              

Spring  14  

08  Fall  

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Introduction    

This  semester  I  was  fortunate  enough  to  have  my  clinical  education  at  Heritage  Valley  Health  System  in  Sewickley.  There  were  many  areas  of  the  HIM  department  that  I  was  exposed  to  during  my  clincals  at  Sewickley,  but  a  large  amount  of  time  was  concentrated  on  the  Forms  Committee  that  my  supervisor,  Tina  Wood,  had  taken  over  responsibility  for.    

The  Forms  Committee  is  composed  of  a  group  of  representatives  from  various  departments  (from  both  Sewickley  and  Beaver  sites)  that  meet  bimonthly  via  webcam  to  discuss  the  status  of  various  forms;  editing  and  reviewing  them  to  ensure  that  they  are  compliant  with  not  only  the  hospital,  but  also  Joint  Commission,  before  finally  approving  them  and  introducing  them  into  the  Heritage  Valley  Health  System  facility.  These  forms  range  anywhere  from  Physician’s  Orders  forms  to  alcohol  abuse  surveys.  Mark,  who  had  clinical  with  me,  and  I  had  the  chance  to  sit  in  on  these  meetings  every  week  and  Tina  would  give  us  each  a  copy  of  all  the  forms  before  the  meeting,  so  that  we  could  go  through  them  ourselves  and  look  for  mistakes.    

Because  Forms  Committee  was  an  activity  that  Mark  and  I  would  take  part  in  every  week  we  were  at  clinical,  we  both  became  very  familiar  with  the  process  the  hospital  went  through  to  approve  forms,  and  also,  in  a  way,  invested  to  the  progress  of  these  forms.  It  was  because  of  this  that  I  decided  to  base  my  Quality  Assessment  project  on  the  compliancy  of  forms  at  Heritage  Valley  Health  System.      Purpose       The  compliancy  of  forms  is  a  very  large  part  of  having  an  efficiently  operating  health  system  anywhere.  The  significance  of  having  compliant  forms  at  Heritage  Valley  Health  System  –  Sewickley  is  no  exception.  There  were  many  issues  that  I  found  were  quite  constant  in  the  forms  in  discussion.  The  three  categories  I  could  place  the  majority  of  the  issues  found  would  be  1.)  Incorrect  or  inaccurate  abbreviations,  2.)  Inconsistencies  throughout  a  single  form  and/or  multiple  forms  and  3.)  General  spelling  and  grammar  errors.  During  meetings  there  would  be  moments  of  miscommunication  between  the  two  sites,  confusion  and  disagreement,  and  I  also  believe  that  the  level  of  efficiency  to  complete  these  forms  was  affected  by  the  miscommunication,  and  thus  the  progress  in  general  was  deterred.      Approach       As  previously  stated,  I  conducted  this  study  by  gathering  forms  used  at  Heritage  Valley  Health  System  and  analyzing  the  forms  for  their  errors  and  inconsistencies.  In  order  to  properly  assess  all  aspects  of  the  intended  goal,  I  followed  the  FOCUS-­‐PDSA  model.    The  FOCUS-­‐PDSA  Model:    

F-Find/define the problem

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O-Organize a team C-Clarify the process U-Understand the process S-Select the improvement P-Plan the improvement D-Do the improvement S-Study/check the improvement A-Act on results  Focus/Define  the  Problem    

The  first  step  according  to  the  FOCUS-­‐PDSA  model  is  to  properly  define  the  problem.  The  purpose  of  this  study  is  to  discover  the  root  of  the  issue  of  why  the  forms  that  are  given  to  the  Forms  Committee  have  the  errors  that  they  do.    

In  order  to  do  this,  I  constructed  an  Excel  spreadsheet  and  listed  four  categories  in  which  the  errors  found  in  twenty-­‐five  randomly  selected  forms  could  be  defined.  Along  with  the  four  categories,  I  added  an  additional  column  that  listed  the  proof  number  (the  number  of  times  the  form  had  previously  been  reviewed)  and  another  column  stating  whether  or  not  the  form  was  compliant.      Figure  1:  Forms  Worksheet    

   

As  depicted  by  Figure  1,  it  is  evident  that  the  biggest  issue  that  arose  out  of  all  the  forms  as  a  collective  unit  was  due  to  wrong  abbreviations.  Following  that,  many  of  the  forms  showed  a  lack  of  consistency  in  the  wording  or  abbreviations  that  they  used.  Out  of  all  twenty-­‐five  forms,  only  twenty-­‐one  were  compliant.    

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Organize  a  Team      

  Heritage  Valley  Health  System  has  a  Forms  Committee  that  handles  all  the  matters  that  deal  with  forms  within  their  health  system.  The  members  range  from  my  own  supervisor,  the  head  of  the  Forms  Committee  and  Medical  Records  department,  Tina  Wood,  to  representatives  of  other  departments  of  the  hospital,  such  as  nursing,  surgery  and  pharmacy.         Before  Ms  Wood  took  over  the  Forms  Committee,  the  members  beforehand  did  not  have  an  efficient  system  for  looking  over  the  forms  and  making  sure  they  were  compliant  with  Joint  Commission  and  the  hospital.  Because  of  this,  when  Ms  Wood  took  over  the  committee,  they  had  extra  ground  to  cover  from  the  previous  Forms  Committee.       Between  the  Forms  Committee  members  at  Heritage  Valley  Health  System  Sewickley  and  Heritage  Valley  Health  System  Beaver,  who  attend  the  meeting  via  webcam,  every  member  has  something  to  offer  to  the  problems  with  the  forms  and  is  willing  to  voice  their  opinion.  There  are  no  members  that  take  a  back  seat.  This  is  important  in  a  team;  that  all  the  members  contribute.      Clarify  and  Understand  the  Problem    

Most  problems  that  had  to  do  with  the  abbreviations  sprouted  from  either  certain  letters  being  capitalized  when  they  ought  not  be,  as  something  as  small  as  capitalization  does  indeed  affect  the  meaning  of  an  abbreviation,  to  lack  of  punctuation  between  letters,  to,  in  general,  the  illegal  abbreviations  on  the  Do  Not  Use  List.      

The  issue  with  consistency  varied  from  within  a  single  form,  to  from  form  to  form.  For  example,  a  single  form  might  have  “grams/mL”  and  “G/mL”  in  the  same  document.  Or,  one  form  could  feature  one  version,  while  other  forms  would  have  the  other  version.  This  causes  confusion  and  in  general  does  not  look  as  clean  as  having  a  universal  word  or  phrase  to  use  within  all  the  different  forms.    

As  for  spelling  and  grammar,  many  of  the  mistakes  were  simple  mistakes  that  could  easily  be  overlooked,  such  as  “then”  versus  “than”  or  “effect”  versus  “affect”.    

Formatting  problems  arose  from  areas  where  the  form  was  not  as  clear  as  it  could  be,  and  from  where  problems  would  be  able  to  arise.  Examples  of  this  could  be  an  unclear  area  for  the  physician  to  write  his  notes  or  even  repetitive  things,  such  as  two  places  on  a  single  form  to  write  the  date.  

    On  the  following  page,  Figure  2  shows  the  amount  of  times  each  issue  arose  out  of  the  twenty-­‐one  documents  that  showed  discrepancies.  The  four  empty  areas  represent  the  four  documents  that  were  compliant.      

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Figure  2:  Form  Compliancy  Issues  in  Each  Document

   

From  this  graph,  one  can  see  there  is  noticeably  more  blue  than  any  of  the  other  colors,  and  that  red  is  quite  prominent  as  well.      Benchmarks  and  Standards    

The  data  that  was  uncovered  after  analyzing  the  forms  was  categorized  according  to  Joint  Commission  standards,  Heritage  Valley  Health  System  Form  Checklist,  the  Do  Not  Use  Abbreviations  List  and  the  ISMP’s  Guidelines  for  Standard  Order  Sets.    

The  benchmark  set  by  Joint  Commission  is  100%  compliant.  Because  forms  had  not  been  reviewed  annually  up  to  this  point  at  Heritage  Valley  Health  Systems,  as  Joint  Commission  states  they  should  be,  it  adds  more  work  to  those  in  the  Forms  Committee  today.    

Since  my  project  is  based  on  forms  under  speculation,  it  is  expected  that  most  of  them  are  not  compliant,  as  there  has  to  be  some  reason  that  they  are  being  reviewed  and  updated.    However,  there  are  those  forms  I  came  across  that  were  approved  during  meeting.    

   Referencing  the  Excel  worksheet  with  the  twenty-­‐five  forms  I  reviewed,  the  

chart  on  the  following  page  depicts  the  breakdown  of  the  number  of  compliant  to  not  compliant  forms  that  I  pulled  and  reviewed.    

 

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Figure  3:  Form  Compliancy  Status    

   

As  depicted,  the  number  and  percentage  of  forms  under  review  that  are  still  not  compliant/being  edited  versus  the  ones  that  are  properly  updated/approved  is  much  less  than  what  Joint  Commission  wants.  I  do  believe  that  if  this  benchmark  were  compared  to  all  of  the  forms  at  Heritage  Valley  Health  System,  the  majority  would  be  compliant.      Select  the  Major  Cause    

After  reviewing  the  forms  and  constructing  the  Excel  spreadsheets  and  creating  various  graphs,  it  was  quite  simple  to  classify  which  issue  was  the  most  common  within  the  forms  at  Heritage  Valley  Health  System.  

As  stated,  it  is  evident  that  wrong  abbreviations  are  the  most  prominent  and  biggest  contributor  in  regards  to  the  compliancy  issues  within  the  forms  at  Heritage  Valley  Health  System.  A  lot  of  this  has  to  do  with  the  ease  of  making  mistakes  and  overlooking  typos.  It  is  also  quite  possible  that  authors  of  forms  might  assume  what  an  abbreviation  for  something  is,  thinking  that  it  is  obvious,  before  a  reviewer  or  the  Forms  Committee  realizes  that  it  is  incorrect.  Human  error  can  very  easily  be  present  when  abbreviations  in  forms  are  the  subject  at  hand.  A  simple  typo  or  an  accidental  capital  letter  could  be  the  difference  between  one  abbreviation  versus  another.    

 

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In  the  figure  on  the  following  page,  a  pie  chart  gives  a  visual  representation  of  the  breakdown  of  the  different  causes  linked  to  the  form  compliancy  issues  at  Heritage  Valley  Health  System.  As  you  can  see,  the  blue  (abbreviations)  section  takes  up  almost  half  of  the  pie  chart.      Figure  3:  Percent  Breakdown  of  Compliancy  Issues  

   Plan       After  spending  time  in  Forms  Committee  every  other  Thursday  and  having  a  first  hand  experience  of  what  takes  place  during  these  meetings  in  conjunction  with  being  able  to  go  through  and  analyze  various  forms  under  speculation  of  Forms  Committee,  I  was  able  to  grasp  a  strong  understanding  and  opinion  on  how  the  Forms  Committee  and  in  general,  form  making,  could  be  streamlined  and  made  to  run  more  efficiently.         Actions  that  I  thought  could  help  in  adapting  a  more  efficient  system,  were  to  help  formulize  a  more  standardized  and  organized  way  of  evaluating  and  reviewing  forms  through  creating  an  environment  where  all  the  standards  and  rules  related  to  the  forms  were  understood  and  well  known  throughout  the  Forms  Committee,  and  to  just  remind  individuals  to  proofread  their  work.  Through  these  actions,  the  target  goal  of  having  all  compliant  and  clean  forms  at  Heritage  Valley  Health  System  can  be  achieved.         My  recommendations  were  to  hire  at  least  three  new  members  or  even  create  a  subcommittee  that  is  meant  solely  to  review  the  forms.  Many  mistakes  or  

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typos  could  have  been  caught  much  easier,  but  due  to  the  fact  that  everyone  in  Forms  Committee  already  has  responsibilities  in  their  department,  not  everyone  has  adequate  time  to  sit  down  and  scrutinize  forms  after  a  long  day  at  work,  especially  if  there  are  already  pressing  matters  within  their  own  departments.  By  bringing  in  new  members  or  creating  a  subcommittee  that  has  no  other  obligations,  it  would  lessen  the  load  on  those  that  have  other  responsibilities  whose  time  commitment  may  be  restricted,  and  also  give  pairs  of  fresh  eyes  a  chance  to  look  over  the  forms  and  catch  things  that  could  have  been  overlooked.     Members  could  also  correct  errors  as  soon  as  they  are  found,  as  opposed  to  waiting  until  Forms  Committee  meetings.  As  the  Forms  Committee  stands,  authors  and  reviewers  of  forms  will  bring  up  certain  errors  during  meeting,  and  while  it  may  be  a  positive  thing  to  discuss  the  issue  with  others,  it  takes  up  a  lot  of  time  that  could  be  used  to  touch  on  another  form.  If  the  mistake  is  corrected  when  it  is  found,  the  person  who  found  the  error  could  just  mention  the  change  during  meeting,  and  then  move  on  from  there.  If  this  system  is  put  in  place,  a  lot  of  time  would  be  saved  and  be  sectioned  more  efficiently.  More  forms  would  be  approved  and  covered  during  the  hour  that  Forms  Committee  meeting  covers.     Another  recommendation  is  to  assign  specific  form(s)  to  a  specific  person  or  persons.  This  way,  every  one  knows  whom  to  consult  for  any  given  form.  This  would  reduce  confusion  and  trafficking  of  e-­‐mails  to  figure  out  whom  to  contact  for  whichever  form.  Time  and  energy  would  both  be  saved  this  way.  Currently,  every  form  has  an  owner,  although  a  problem  that  I  noticed  is  that  there  is  general  confusion  as  to  what  form  belongs  to  which  person.  This  leads  me  to  another  suggestion,  the  implementation  of  an  online  site  where  members  of  the  Forms  Committee  can  log  on  and  see  which  form  belongs  to  which  person.  An  example  would  be  sharing  a  Google  doc  link.  That  way,  along  with  stating  who  has  what  form,  as  updates  are  being  made,  the  person  making  updates  can  go  along  and  update  it  on  Google  docs  for  all  to  see.    Below  is  an  example  of  what  this  spreadsheet  could  look  like.      

     

 

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Making  extra  strides  toward  being  confident  that  each  reviewer  has  a  clear  understanding  of  what  the  standards  and  rules  are  could  make  all  the  difference  when  it  comes  starting,  developing  and  finishing  a  form.  Each  member  should  be  distributed  a  copy  of  all  the  rules  and  standards  that  need  to  be  followed.  These  copies  should  be  consulted  each  time  a  form  is  being  made.       Lastly,  something  as  simple  as  remembering  to  proofread  could  save  a  form  from  having  to  go  through  the  tedious  cycle  of  being  edited  for  a  minor  error.  Each  reviewer  should  double  check  and  proofread  one  more  time,  even  after  they  think  the  form  is  compliant  and  consistent,  and  that  those  few  extra  minutes  glancing  over  the  form  could  save  hours  to  even  days  of  unnecessary  e-­‐mail  exchange  and  processing.  There  should  be  no  reason  for  a  proof  number  higher  than  three  on  any  form.            Do       Since  starting  Clinical  Education  at  Heritage  Valley  Health  System  in  Sewickley,  the  Forms  Committee  has  become  more  efficient  after  each  visit.  The  two  most  recent  and  my  final  meetings  that  I  attended,  on  March  20,  2014  and  April  3,  2014,  passed  forms  to  be  printed  and  also  concluded  early;  two  things  that  rarely  happened  during  the  meetings  attended  during  the  start  of  my  clinicals  here  at  Sewickley.  It  might  not  be  seen,  but  it  is  very  obvious  that  a  lot  of  work  is  being  done  behind  the  scenes  to  facilitate  the  process  of  approving  forms  that  are  completely  compliant  with  the  Joint  Commission.       The  Forms  Committee  has  also  decided  to  start  correcting  forms  as  mistakes  are  being  found,  rather  than  waiting  for  the  meeting.  By  looking  over  at  these  forms  before  meetings  start,  the  time  spent  on  each  form  was  shortened  greatly  and  the  meetings  even  concluded  before  the  hour  passed.      Study       The  result  of  implementing  even  one  of  the  recommendations  made  the  meeting  run  more  smoothly  than  before  and  more  forms  were  approved  those  days  than  had  been  on  any  previous  days  that  I  attended  the  Forms  Committee.       Every  time  Forms  Committee  meets,  progress  is  being  made  and  clearer  understanding  on  how  to  achieve  the  target  goal  becomes  closer  and  more  in  sight.  Heritage  Valley  Health  System  a  few  years  back  had  switched  vendors,  causing  a  lot  of  back  track  due  to  having  to  send  all  of  their  forms  to  R.R.  Donnelly,  their  new  and  current  vendor.  Even  with  the  extra  load,  the  increase  in  productivity  during  meetings  has  improved  every  time  and  steps  are  being  made  toward  the  right  direction.      Action       The  Forms  Committee  should  form  a  subcommittee  dedicated  to  reviewing  the  forms,  especially  those  belonging  to  physicians,  for  they  are  better  suited  to  look  for  small  errors  that  can  easily  be  missed  by  the  members  who  do  not  have  a  lot  of  

10  

time  to  dedicate  to  reviewing  forms  or  have  other  matters  at  hand.  Forms  should  be  reviewed  prior  to  attending  the  meeting  and  mistakes  should  be  marked  accordingly.  That  way,  when  the  form  is  discussed,  there  will  not  be  time  wasted  on  reviewing  it  too  in  depth  there,  because  most  if  not  all  of  the  errors  were  already  caught  when  it  was  being  reviewed  beforehand.     Currently,  there  is  some  type  of  distribution  of  what  forms  belong  to  what  person,  but  it  could  be  neater.  I  think  that  there  should  be  an  internet-­‐based  spreadsheet,  such  as  the  Google  doc  suggested  earlier,  that  is  accessible  only  be  Forms  Committee  and  subcommittee  members  and  also  a  printed  monthly  or  bimonthly  e-­‐mail  so  that  there  is  an  updated  hard  copy  if  ever  someone  is  working  on  forms  without  the  internet.  This  spreadsheet  should  at  least  state  the  forms  that  are  currently  being  written  or  reviewed,  the  proof  number,  and  a  name  and  e-­‐mail  address  of  the  person  who  is  in  charge  of  that  form.  This  would  diffuse  much  of  the  communication  issues  that  take  place  when  the  vendor  does  not  know  what  the  Forms  Committee  member  is  working  on  who  does  not  know  what  the  Information  Systems  person  in  charge  of  Allscripts  is  working  on.  Everyone  would  be  able  to  keep  up  with  the  progress  as  a  collective  unit  and  also  know  that  revisions  are  being  made  on  the  most  recent  proof.    

In  addition  to  working  together  as  a  group,  I  would  like  to  see  every  member  of  the  Forms  Committee  have  a  copy  of  the  standards  and  rules  by  Joint  Commission,  ISMP  and  Heritage  Valley  Health  System  at  their  disposal,  so  that  they  may  be  able  to  consult  them  whenever  they  are  the  slightest  bit  unsure.  I  would  even  recommend  having  the  rules  and  regulations  laminated  and  posted  in  different  parts  of  the  hospital,  especially  in  the  offices  of  those  in  the  Forms  Committee.  

Also,  proofread.  If  members  were  just  reminded  to  proofread  whenever  they  have  a  spare  minute,  a  lot  of  trouble  could  be  avoided  and  time  could  be  saved.      

Heritage  Valley  Health  System  has  been  a  great  experience  for  me  to  learn  about  the  good  and  bad  of  “the  real  world”.  This  hybrid  hospital  is  full  of  hard  workers  that  just  have  a  lot  of  catching  up  to  do  from  previous  form  undertaking.  I  believe  that  all  of  these  recommendations  and  actions  are  in  an  effort  for  a  smoother  system  at  Heritage  Valley  Health  System  and  could  bring  success  as  an  end  result.