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Special Coverage: AHIMA’s 74th Conference
Go beyond requirements; make positive impression
Evidence binders show you really care
It’s not always easy to make a good impression on a surveyor for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) of Oakbrook Terrace, IL, but it can be done.
Ray Pinder, MS, RHIA, director of medical records at Holy Redeemer Hospital and Medical Center in Meadowbrook, PA, has found that sometimes it takes an added measure of preparation to show surveyors that an organization has made quality a top priority. Pinder spoke about preparing for a Joint Commission survey at the 74th National Convention and Exhibit of the American Health Information Management Association (AHIMA) of Chicago, held Sept. 21-26 in San Francisco.
Pinder offers these hints for making a JCAHO surveyor take positive notice of your facility:
• Presentations: "When we have a Joint Commission survey, we put together a storybook presentation," Pinder says. "We bring examples of things that will demonstrate improvements and put these on display so that the surveyor can look at these if there is time."
Pinder also prepared a PowerPoint presentation to demonstrate the full Ongoing Record Review (ORR) process.
The presentation highlighted Holy Redeemer’s ORR process from beginning to end. Included in the presentation were a few documentation improvement projects that were highlighted for surveyors.
Presentations may spur questions
During a 90-minute medical record interview, there typically is a 15-minute time slot allotted for an overview of the facility’s ORR process, Pinder says.
"At that point, the team leader should ask if it would be okay to do a PowerPoint presentation," Pinder says. "Our survey team agreed, and enjoyed the 15-minute presentation."
However, be aware that such a presentation may lead to more questions: "As the surveyors were watching and listening, I noticed lots of jotting of notes," Pinder recalls. "At the conclusion of my PowerPoint presentation, the surveyors asked several questions, some that were about details within the presentation."
Pinder says the surveyors made positive comments about the presentation and about how their questions were answered appropriately, which emphasizes the fact that a presenter should be well-prepared to explain all details.
• Evidence binders: Pinder is an advocate of evidence binders as tools that are kept up to date. These provide an organized look at how well a facility is prepared for a survey.
The Holy Redeemer Hospital’s evidence binder has 10 sections, including one for each standard. These include intent statements, answering the question of how an organization would meet a standard, and a definition of the evidence that would demonstrate it has met that particular standard.
The medical record review evidence binder contains 12 months of a review tool, completed studies, any deficiencies noted, any letters to the medical staff or ancillary departments regarding documentation, and requests made to submit action plans with regard to deficiencies, Pinder says.
For example, the information management standard for ongoing record review would include, in the binder, copies of monthly study results and action plans from those studies for all items that need to be addressed, Pinder says.
"And those reports are sent to the various committees, the hospital quality improvement committee, and all the way up to the medical executive committee," he says.
• Original tools and forms: "Many times surveyors are impressed by a new type of form or documentation, and they may ask how it was devised and improved and whether it has improved outcomes," Pinder says.
Surveyors at times have even asked Pinder if they could have a copy of the form that was created at Holy Redeemer Hospital so that they could share it with their own facility, Pinder says.
"Most surveyors do surveys on the side, and they like to keep an original form in a file so that when they go out to other facilities, they can say, I came across this form and it may help you as well,’" Pinder explains.
• Higher goals than what’s required: Although the Joint Commission sets a goal of having 50% of a facility’s records being completed within 30 days, the HIM department should raise the bar to 90% to 95%, Pinder suggests.
"The Joint Commission will ask for four quarterly measurement periods, the last four quarters, to see what were the percentages of delinquent medical records," Pinder says. "They use the threshold that you must be above 50% on time."
Sometimes it’s difficult to obtain completed records from physicians and other health care providers within 30 days, but if a facility would like to impress a Joint Commission surveyor, it’s a good idea to do far better than the 50% threshold, Pinder says.
Holy Redeemer sometimes had on-time percentages above 70% to 80%, he adds. "The surveyor was pleased with that."
However, the organization’s goals are even higher. "Our goal would be that at least 95% of the documentation elements, such as diagnoses on the discharge summary, would be completed on time," Pinder says. "If the level is at 90%, then we will send out letters of how we’ve fallen five points below our acceptable standard."