Internal audit prepares practice for surveys
Goal is 85% compliance with chart requirements
Every three months, a quality improvement nurse at Atlanta Ear, Nose & Throat Associates targets a procedure or diagnosis and pulls a sample of patient charts. She is as exacting as a surveyor from a health plan or accrediting organization as she conducts a review.
Were allergic reactions documented? Were patient information sheets filled out correctly? Did the physician record smoking habits or alcohol use? She expects the answer to be "yes" in at least 85% of the charts she pulls.
By conducting its own regular, internal audits, the 25-physician practice prepares for health plan audits for its practice and two related operation networks it manages, improves its stature in managed care negotiations, and provides a method for monitoring clinical quality issues, says administrator Larry Kraska.
"We wanted to maintain a high standard of good clinical documentation so we could demonstrate we were providing good quality care to our patients," says Kraska.
Kraska notes that Physician Specialty Corp., which manages the practice and two related capitation networks, conducted medical record audits and maintained a clinical committee before either was required by the National Committee for Quality Assurance, which accredits health plans.
Since managing a capitation network means taking on many functions of a health plan, those chart audits include a review of compliance with specific treatment protocols.
Those protocols aren’t applied to the overall practice. But the audits have led to better documentation in all charts and has highlighted areas for the clinical committee to discuss, says Rosemary Matthews, director of managed care services.
The quality improvement nurse uses an audit checklist to conduct her review, which includes a periodic facility assessment of the practice’s 25 offices. (For a sample checklist, see box, at left.)
The reviews bring records to a higher level of documentation, says Matthews. For example, the record will be cited if it mentions a patient allergy but doesn’t detail the nature of an allergic reaction.
Notations of drug use should include both prescription and over-the-counter medications. For pediatric patients, the chart should note whether there are any pets in the house.
Even doctors’ dictation styles improve
Audits have led physicians to improve their dictation of notes, Matthews says. "You need a good history, your assessment and findings, and your plan," she says. "Some doctors can dictate two or three pages, some can do it in one paragraph."
After one of the practice’s physicians sees a patient, staff send a letter with a copy of the physician’s notes to the referring physician. That also is documented in the record. "Insurance companies are looking for open communications with referring physicians," says Matthews.
At the end of the audit, physicians receive a report, just as they would from a health plan. It lists the areas reviewed and provides a score that indicates what percentage of charts were in compliance. The practice sets a standard of 85% compliance but often exceeds 90% or attains 100%, says Matthews.
Even with the high rates of compliance, the practice’s clinical committee sets an annual action plan and tries to improve its performance in a variety of areas, including documentation, patient satisfaction, wait times, and clinical issues. "We’re constantly trying to find ways to make it better," says Kraska.
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