Signing, dating, and timing your verbal orders: Are you in compliance?

Suggestions from the field

It's nothing new. Compliance with verbal orders has been a struggle for hospitals for more than 25 years. Many experts Hospital Peer Review spoke with compare verbal-order compliance to hand-washing compliance. It's behavioral. It's something we know we have to do. And it's not a matter of ill-intentioned practitioners. It's a matter of time and logistics.

"It's something we all know is right; we all know the right way to do it. It's just a pragmatic issue of how do you get it done," says Patricia C. Kienle, RPh, MPA, FASHP, director, accreditation and medication safety, quality, and regulatory affairs for Cardinal Health Pharmacy Solutions. So what can you do to get your compliance rates up?

As it is now, Joint Commission-accredited hospitals must have verbal orders authenticated, timed, and dated within a 48-hour time frame. And that authentication can be handled by covering physicians. Of course, stipulations can vary state to state. The "sleeping giant," says Ruth Elzer, RN, MS, principal, accreditation and compliance services with Compass Clinical Consulting in Cincinnati, lies with the Centers for Medicare & Medicaid Services (CMS). According to its interpretive guidelines, beginning in 2012, no one but the prescribing provider can sign verbal orders. And everyone expects that The Joint Commission will fall in line with this, though, Ken Powers, media relations manager, says, "The Joint Commission will see what CMS implements before determining a response."

Minimize verbal and phone orders

You should have a policy in your hospital's rules and regulations that essentially discourages verbal orders, that states the use of verbal orders should be minimized and reserved for emergency situations, says John R. Rosing, MHA, FACHE, vice president and principal in Patton Healthcare Consulting's Milwaukee office. You must have this stated in your regulations, and he says The Joint Commission will want to see that. If you can't locate that or if it's not included, you might be cited.

"The first and foremost thing [with verbal-order compliance] is that we're trying to get practitioners out of the habit of using a lot of verbal orders, because there are compliance considerations that come along with verbal orders. One challenge is to decrease the overall number of verbal orders that are given in a given day, reserving them for emergency situations, procedural times, and middle-of-the night emergencies. That will decrease the overall requirement burden just by the sheer number of orders that have to be dealt with," Elzer says.

Kienle says the hospitals she visits that are most successful have ratcheted down the number of verbal and telephone orders. But this "takes a culture shift," she says. And there always will be situations where verbal or telephone orders are necessary.

Watch your verbs with TJC

Joint Commission surveyors will check charts along their tracers, but they also will ask providers, "'How do you take a telephone order if you need to? What's the process you walk through?' And what they're looking for is a consistent answer out of everyone they ask that says very clearly, 'What we do is we write down an order — either if it's on a piece of scratch paper, preferably we have the chart with us — and we write it in the order section. But sometimes we might be down the hall or somewhere where we can't get the chart. Nonetheless, we write it down and then we read it back to the physician for confirmation.' And so the surveyor hears that three or four times and they think, 'OK I'll move on,'" says Rosing.

"If, on the other hand, they hear something different, such as 'I repeat it back and then write it down' — in other words, they reverse the order and also use the verb 'repeat' instead of 'read' — they're very riveted on this and their ears are perked up to listen as to whether the verb used is repeat or read. And if it's read, you're in good shape. If it's repeat, you're going to be in trouble," he says.

Do fines work?

Compliance, Elzer says, is a combination of many things. "Usually you try to help, you try to facilitate. You talk to the docs and say, 'What would have helped you better do this?'"

Many hospitals have implemented fines for noncompliant practitioners. Some find that helpful; some find it unnecessary. Usually the first step in becoming compliant is flagging, Elzer says — flagging orders that have to be signed and color coding the flag to identify which group of practitioners need to look — for instance, red for heart surgeons and blue for ED physicians.

But, she says, "some organizations that have dealt with this on a long-term basis haven't been able to get the physicians to turn around by gentle reminders. And they start looking at, 'How can we kick this up a notch?'"

Some hospitals, she says, have stipulated that if your verbal compliance is poor, providers must pay more of their dues, or discounts for dues are waived. "I think what is a very effective and irritating [thing] for docs is if you take away their privileges in the cafeteria... It's an irritation factor," she says.

Rosing says some organizations he's worked with have found innovative ways to incentivize physicians to be aware of verbal order requirements. "For instance, they might take the dollars that are coming in from the fines and donate them to a homeless shelter in the community. And just make a big deal about certain people who have improved over time," he says.

He helped one hospital find a unique and humorous way to bring physicians into compliance. He found cards that play a customized recorded message when you open them. They recorded an MP3 file and attached the card to charts so when physicians opened them, they would hear the eight-second recording: "Please sign, date, and time your verbal orders. Damn it!"

"It brought awareness to the issue, and they got a little better compliance with it," he says.

But Kienle finds punitive measures such as fines and removing cafeteria privileges a "Draconian move."

"That may work for short periods of time. But we're all professionals, and that carrot and the stick thing just doesn't do much for me, especially on the punishment side," she says.

She finds more success "if administration is clear in their intent to truly do this for the right reasons. You know, that it's a safety issue. 'We want to avoid transcriptions. We want to avoid misinterpretations.' It has to come from the top to make it successful for the people who are in the trenches doing this," she says.

Rosing thinks it's helpful for someone the physicians respect to speak one on one with them, whether that be the vice president of medical affairs, the chief medical officer, or an administrator. He suggests telling physicians, "'Hey, this is simply a requirement that we have to fulfill. And we need your assistance. How can we make it easy for you? Flags? But bear in mind, we're not going to waste our time doing this if you're not going to pony up and sign it. So it's a two-way street on that,'" he says.

The other thing he suggests that resonates with physicians on a personal level is to say, "When you don't sign a verbal order, you're compromising your colleague," putting that coworker at risk by carrying out something that wasn't authorized by a licensed independent practitioner.

"That's kind of a harsh thing to say, but with some physicians that's the approach I would take. To say, 'Look you're being disrespectful here… you're putting the nurse in a compromised position and that's not fair to them. You need to hold up your end of the bargain and carry out your responsibility. You went to medical school. You have the privilege to order medical treatment, and this is part of that privilege.'"

How to use data

Rosing suggests getting away from traditional and timely QI approaches and to simply visit a department and ask a seasoned nurse there, "Who is not signing their verbal orders?"

"And they'll tell you in 30 seconds who the people are," he says.

Rosing and Kienle agree that it's usually the 80/20 rule. That is, most of the physicians are not having problems. It might be a smaller group who are not complying, but that's where you have to maintain the focus.

"You may think it's a housewide issue, but when you start digging down into the details, which is very labor-intensive to do but may be worth doing once and identifying that it's this one physician, or it's this one drug we need, or it's a certain time of day, or it may be just a staffing issue," Kienle says.

"And I have seen people successfully identify those pieces that are causing most of their problems, put a fix in, and then subsequently checking it to make sure that fix has worked," she says.

The process is labor-intensive, she says, because you have to look through the charts. "And if people are Joint Commission-accredited, there's certain criteria about sampling, how many records you would need to look at to identify problems.

"It's always a good idea to have some baseline data," Kienle says. "So I think it's worth a short period of time or a certain number of charts to take a look through that, see the verbal orders, who's writing them. Is it a specific service, is it a specific drug or lab test or whatever? Are the hospital policies being followed? Is the signature there and date and time and things like that? And then make some assessment. 'Do we need to go after certain physicians? Certain groups? Certain drugs? Certain lab tests?'"

Your root-cause analysis, when an error has been made, may offer "a little more ammunition" as well when you speak to a physician. Kienle also advises hospitals to make sure they're complying with all of the standards regarding verbal orders, which, she says, "weaves its way among several of the [Joint Commission's manual] chapters. We used to focus on the National Patient Safety Goal and the medication management chapter. But now there's also wording about verbal orders in the provision of care chapter and in the record of care chapter. So people need to be sure, if they're Joint Commission-accredited, that they are certainly complying with all three of the standards" — MM.04.01.01 EP6, PC.02.01.03 EP20, and RC.02.03.07.

She also sees most of the burden lying in the hands of nurses. "But we have to remember, it's not just nursing. It's anyone who could take a verbal order. So it could be lab, it could be pharmacy, it could be physical therapy, it could be respiratory, and everybody needs to be doing things the same way in the facility... It's real tough for the nurse to be standing out on her own and the only one in the organization saying, 'Here doctor, write this.' It has to be a housewide issue."

She points to "ASHP: Guidelines on preventing medication errors in hospitals" as a resource, which suggests:

  • use special caution when prescribing drug doses in the teens;
  • when reading back, the drug name should be spelled to the provider with no abbreviations used.

She also suggests looking at recommendations from the National Coordinating Council for Medication Error Reporting and Prevention (