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Surveyor looks at charts, physician credentialing, QI

Ambulatory Safety Monitor, March 24, 2005

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When the Hawthorn Endoscopy Center of North Dartmouth, MA, opened five years ago, it sought accreditation because BlueCross BlueShield of Massachusetts required it for a contract.

As the practice grew, however, Susan Socha, RN, director of nursing at the endoscopy center, found that a lot of patients asked about accreditation affiliation. "Patients are concerned with safety and want to know we can handle emergencies," she says. "Accreditation reassures them your processes are good."

Work toward success every day

The AAAHC surveyor who reviewed Hawthorn for two days during its second survey in July 2004 was most impressed by the organization's charts. "He said they were the best charts he'd seen because they were thorough and complete," and because the order of items was consistent, Socha says.

The organization received no suggestions for improvement in this area, which it works on constantly throughout the year. Before Socha files the charts, she reviews each one. She checks the completeness of each file and returns them to the providers if anything is missing. For example, nurse and physician drug dosages must match and providers must fill in all necessary signatures.

To help lessen some of the labor involved in checking every file, the organization uses a software program that keeps charts neat, professional, and easy to maintain. Hawthorn also uses computerized patient scheduling. Although many organizations can't afford to update their technology, the manual method also works well, as long as all procedures are consistent. For example, in Hawthorn's software program, physicians enter the information into the computer and nurses handwrite their notes on the printouts.

The surveyor also reviewed the organization's physician credentialing process. Credentialing success depends on keeping this information up to date, Socha says. "Set aside time for it often and don't wait until the last minute," she recommends.

The learning process never ends

Hawthorn received a few suggestions for improvement. Because of the amount of narcotics the center deals with, the surveyor suggested bringing in a pharmacist consultant to review the organization's procedures and offer ideas for a better process. The surveyor advised them to add a diagnostic summary sheet to their charts for patients who had visited the center more than once.

He also advised the facility about how to conduct better quality improvement (QI) studies. Many organizations don't receive training on how to do these studies, and learn as they go. The AAAHC offers the Institute for Quality Improvement, which provides educational programs and clinical performance measurement opportunities for ambulatory organizations that want assistance in QI studies (see the AAAHC Web site, http://www.aaahc.org, for more information).

The Institute for Healthcare Improvement (IHI) suggests starting any QI study with a team and proper leadership. Identify an enthusiastic and respected clinician as a team leader who will champion the work and partner with upper management, and an improvement team to spearhead the project. Give the team ample time to perform and regularly evaluate studies (see the IHI Web site, http://www.ihi.org, for more information).
 

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