Special Coverage: AHIMA’s 74th Conference in San Francisco
Care and detail go a long way in preparing for Joint Commission survey
One HIM department sails through process
[Editor’s note: Hospital Payment & Information Management newsletter is providing special coverage of the 2002 National Convention & Exhibit of the American Health Information Management Association, which was held Sept. 21-26 in San Francisco. Look for stories next month also about accreditation, coding, quality, reimbursement, and other key issues.]
Every HIM director would like to receive praise from a surveyor of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) of Oakbrook Terrace, IL, following a survey.
This may not always occur, but for at least one hospital’s HIM department, this is exactly what happened.
"The Joint Commission praised us highly this past year at the survey in February 2002, and said we do a very good job at addressing legibility during our reviews," says Ray Pinder, MS, RHIA, director of medical records at Holy Redeemer Hospital and Medical Center in Meadowbrook, PA. Pinder spoke about preparing for a Joint Commission survey at the 74th National Convention and Exhibit of the Chicago-based American Health Information Management Association (AHIMA), held Sept. 21-26 in San Francisco.
"The Joint Commission is concerned about legibility. The way we do things is to have a reviewer look at all handwritten documentation, such as patient’s history, the physical, progress notes, and physician orders, to see if they are timely, dated, signed, and if the information is legible," Pinder explains.
"If the reviewer says, Yes, it’s fine,’ then it’s OK," Pinder says. "If the reviewer says it’s not legible, then we pass it on to another reviewer."
If the second reviewer disagrees with the first reviewer, then a third reviewer would be engaged. The third reviewer’s finding is the one the HIM department would act on, Pinder says. For example, if the third reviewer decided that the information indeed is not legible, a letter would be sent to the person responsible for the documentation to explain the problem and to ask him or her to review and come up with recommendations for improving documentation, such as dictating these notes in the future, he says.
It’s this level of care and detail that has helped to make Pinder’s organization well-prepared when a Joint Commission surveyor walks through the door.
Prepare well ahead of time for survey
Pinder offers these suggestions for other ways that HIM departments might prepare for a Joint Commission survey:
1. Prepare 12-15 months before the expected survey.
For at least 12 to 15 months before the anticipated Joint Commission survey, Holy Redeemer Hospital starts to prepare, beginning with looking at the previous survey report, Pinder says.
"We look to see if there were any Type I recommendations from the Joint Commission at the last survey, and we make sure these have been fully addressed before the Joint Commission comes back for their upcoming survey," Pinder says.
These Type I items should have been addressed within six months of the previous survey through a corrective action plan.
"If you submitted a corrective action plan to the Joint Commission, but have not actually corrected the problems, then it won’t look very good," Pinder notes. "So it’s clear that everyone in an organization, and not just the HIM department, should take a good look at previous recommendations and make sure those have been corrected or at least improved during the 12-month period prior to the next survey."
Also, the organization should review its safety precautions, patient safety, medical records, human resource records, and other documentation at least a year before the survey, Pinder says.
Each month, Holy Redeemer Hospital has a record review in which medical documentation is checked for completeness by a medical record review team.
"We do a sampling of all record types, both inpatient and outpatient," Pinder says.
2. Review the 19 standards regularly between surveys.
Holy Redeemer Hospital’s record review uses the Joint Commission’s part one and part two documentation tool as a master document. Because this document has over 150-plus criteria, it can be used to do several smaller, focused reviews, including the 19 standards required by the Joint Commission, as the medical record review tool, Pinder says.
These 19 standards must be reviewed at least four times throughout the three-year JCAHO survey cycle, Pinder says. "If you don’t receive a three-year accreditation, then you have to make sure you review those 19 standards four times during whatever cycle in which you will next be evaluated."
During the documentation review, reviewers will look for the same sort of items that the JCAHO surveyor would examine, such as operative notes and history and physical exams, and HIM professionals will do a quantitative analysis to make certain the history and physical exam have all of the required components. These include a review of system, past medical history, presenting illness, family history, and a physical exam that includes a quantitative analysis to make certain each body system has been examined and addressed, Pinder says.
"At Holy Redeemer, we use coders as part of the review team, so it’s a learning experience for them," Pinder says.
While coders look for specific data elements, they also begin to think about items they see daily on the medical record, such as face sheet, physical, history, operative notes, consultations, and documentation, Pinder says.
"So those reviews are very critical to the medical record review portion of the Joint Commission survey," he adds.
3. Evaluate medical record charts for necessary information.
"We ask to have all diagnoses and procedures identified within the medical record on the face sheet or coding sheet," Pinder says. "So we do a review of that to make sure we can report back if we are evaluating on a given month that X percentage of records do not have all the diagnostic information needed."
A coder will work through the documentation, pulling out additional diagnoses, calling clinicians, and getting their approval to use the diagnoses, Pinder says.
Pinder notes that an industry standard is that a good coder can do three to four charts an hour, provided the coder has good documentation and all ancillary reports for evaluating diagnoses and procedures.
When an HIM director has coders review medical records to improve data and coding quality, this is something that can be quantified to supervisors about why coders are not meeting the average productivity standards, Pinder adds.
"It’s justified because of the time spent to track down the additional information prior to completing the coding session," Pinder says. "You want to bill for everything you legitimately can, and many times it could take more than one call to a clinician to get that information."
Pinder says the ongoing record review system has significantly enhanced the hospital’s coding program. "Documentation is addressed, and we are trying to make improvements so that we do meet the Joint Commission standards, but more importantly so that we can provide information that is needed to provide care," Pinder says.
The reviews also make it easier for other health care workers to review medical records and perform their jobs with a focus on quality.
Mock surveys give chance to practice
4. Hold mock surveys.
During the survey, there may be 12-15 people available to answer the surveyor’s questions. Pinder is usually the team leader of the interdisciplinary team.
"We have rehearsals called mock surveys three months prior to the survey," Pinder says. "One month prior to the survey, we have the medical director and administrator act as surveyors and quiz us on questions, as we do a show-and-tell."
A mock surveyor might ask the team to describe how they measured improvement in verbal orders, so the team would open a binder and show a graph that demonstrates a three-year trend of improvement, Pinder says.
"These rehearsals are very valuable. Even if they are not the real thing, they are intimidating for the team members," he says. "So when the real thing happens, they’re a little more relaxed and answer questions appropriately."
5. Tie loose ends as survey time approaches.
Although the Joint Commission survey dates are usually pre-announced, they now can do unannounced surveys. Even so, there should be plenty of time to complete last-minute preparations within the month before the anticipated survey time, Pinder says.
"If you are using the 12 months prior to the scheduled survey, then your organization should be in a state of readiness," he says. "I make sure I have 12 months of records and documents up to date."
Then, within the month before an anticipated survey, Pinder will pull the HIM staff together to discuss survey interviews and to make sure they feel comfortable with answering questions about any of the 10 information management standards.
"I try to give them a little pep talk about how we’re ready and we can do this so they should just do their very best," Pinder says.
"I believe if the HIM director has done everything to prepare for the 12 months prior to the survey and particularly during the month prior to the survey, then during the week of the survey the HIM director and the HIM staff should be doing business as usual," Pinder says.
Audio conference tackles HIPAA privacy concerns
The recently released final privacy rule under the Health Insurance Portability and Accountability Act (HIPAA) makes significant changes to the existing regulations. With the April 14, 2003, compliance deadline fast approaching, is your staff receiving the proper training?
The American Hospital Association says implementing HIPAA will require "sweeping operational changes" and will take "intense education of hospital workers and patients." To help you and your staff prepare, American Health Consultants offers HIPAA’s Final Privacy Regulations: What You Must Know to Comply, an hour-long audio conference on Dec. 4, 2002, from 2:30-3:30 p.m. Eastern time.
You’ll learn detailed information on changes to the privacy rule, as well as practical methods to implement new procedures within your facility. Also learn how to successfully manage privacy issues with business associates and how to spot and avoid costly HIPAA violations. Do you know what your enforcement priorities are? Do you need real-world examples? Our expert speakers, Debra Mikels and Chris Wierz, BSN, MBA, will help you understand your responsibilities and identify potential liabilities. All this will allow you to develop a HIPAA compliance strategy with a rationale behind it.
Mikels is corporate manager, confidentiality, for Partners Healthcare in Boston. The Partners system includes some of the largest and most respected facilities in the country, including Massachusetts General Hospital, Brigham and Women’s Hospital, and Harvard Medical School. Mikels will provide the practical information and guidance you need to implement a comprehensive privacy policy in your organization.
Wierz is vice president of HIPAA and compliance initiatives for Houston-based Healthlink, a health care consulting firm. She has worked with numerous facilities across the country to prepare them for HIPAA compliance, and now she shares many of her ideas with you.
The cost of the conference is $299, which includes free CE or CME for your entire staff, program handouts, additional reading, a convenient 48-hour replay, and a conference CD. Don’t miss out. Educate your entire facility for one low price.
For more information or to register for the HIPAA audio conference, please call American Health Consultants’ customer service department at (800) 688-2421, or send an e-mail to [email protected]. When ordering, please refer to code B65151B.
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