Accreditation

Learn what one hospital is doing to comply with the unapproved abbreviations goal

Accreditation Connection, August 13, 2004

Stumped on how to get physicians to stop using prohibited abbreviations? Try slapping them below the belt-with a $50 fine from their wallets.

That's the technique recently employed by Saint Thomas Health Services in Nashville, TN, where the $50 penalty is part of a larger patient safety campaign to eradicate confusing expressions and abbreviations from all medical documentation.

Physicians who use abbreviations on the hospital's "do not use" list, such as "QD," are granted two chances to change their ways before Medical Staff President Angelo Canonico, MD, deals them a fine. The hospital's graded enforcement system works like this:

Strike one: First, physicians who use an abbreviation, symbol, or expression on the hospital's do- not-use list receive a friendly, written reminder from the quality officer.

Strike two: If they use a prohibited abbreviation again, they receive a letter and a phone call from the chief medical officer.

Strike three: If they get caught a third time, they receive another missive from the chief medical officer, as well as a $50 fine from the medical affairs department. Physicians are only fined once per year. Proceeds benefit the hospital's medical library. Physicians who choose not to pay the penalty risk suspension of their privileges.

You're out: Four-time offenders get one-on-one face-time with their department chief.

Because the fine benefits the hospital's library, it's not meant to be overly punitive, but does get physicians' attention.

"To be exceptionally punitive seemed unreasonable to us," says Canonico. "We've been using most of these abbreviations since medical school, so it's not an easy habit to change. But without the changes, we'll be in violation of JCAHO requirements."

Previous tactics didn't work

The idea for the fine originated during an April meeting of the medical executive committee where members were brainstorming creative ways to "teach old dogs new tricks" while gently enforcing the hospital's do-not-use list, Canonico says.

As you know, the JCAHO's National Patient Safety Goals require hospitals to standardize the abbreviations, acronyms, and symbols that staff and clinicians use, by creating a list of do-not-use abbreviations, acronyms, and symbols (Goal #2b).

The committee and the quality improvement departments have tried other enforcement tactics with little success, such as posting signs throughout the hospital, writing articles in medical, nursing, and pharmacy staff newsletters, and conducting random chart reviews that resulted in warning letters to offending physicians.

"We've had lots of improvement, but a lot of people still forget," says Deanie Lancaster, RN, BSN, MHSA, CIC, patient safety officer.

When someone tossed around the idea of fining physicians-and to use the money to support the hospital's medical library, the committee quickly approved the idea as a last resort to get physicians on board. So far, no one has been fined, "and hopefully no one will," Canonico says.

And although a few physicians have grumbled about it, no one has voiced a strong objection to the program, he says.

"I haven't gotten any post feedback saying it's a great idea, but it has not caused an uproar either," Canonico says.

A brave step

Lancaster predicts that the hospital's abbreviation and legibility problems will disappear completely once it switches to a computerized charting system in Fall 2005.

Until then, she and Canonico's staff will continue to monitor physicians' compliance with the JCAHO's safety goal requirement.

"Many of us have been writing these abbreviations for the last 20 years," says Canonico. "I even catch myself writing QD and have to say, 'Oh, wait a minute,' and then write 'q day' or 'once daily.'"

It's too early to tell how effective the fee will be, as it wasn't scheduled to go into effect until BOPS' press deadline.

"It may sound a bit draconian to some, but I find it refreshing and actually a brave step," says Lancaster. "We expect a great hue and cry followed eventually by grudging compliance."

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