Information management: Are policies understood?

When undergoing an accreditation survey, be certain your staff are following your own written policies for information management, suggest your peers. Here are some of their tips:

"This is a lot of work, and you have to keep your staff up to date with your policies," says Jerry Henderson, executive director of the SurgiCenter of Baltimore in Owings Mills, MD. The center handles about 11,000 procedures a year. It is accredited by the Accreditation Association for Ambulatory Health Care (AAAHC) in Skokie, IL.

All employees should know your policies, especially the ones that apply to their jobs. "It doesn’t do you any good to have your policies in place if your staff don’t know they’re there and employees are not following them," Henderson says.

A surveyor, for example, may pull aside an employee in your department and ask him or her the policy for sending out notices on late payments. The employee should know the answer.

SurgiCenter posts various policies each month and has employees sign a log showing they read it. When there’s a new policy, it’s circulated to all employees, and again they each sign off on it, he says.

Handling reimbursement issues.

AAAHC surveyors will review a facility’s reimbursement records only partly to see whether the facility is compliant with standards, says Cathy Holmgren, RN, MBA, executive deputy director of AAAHC. "There should be a system of approval on accounts receivable and payable. There should be an authorization process that only certain people are identified as being able to write checks."

The surveyor also will check the center’s rates to make sure patients and payers were charged a rate according to policy. And the surveyor will examine the center’s financial statements, income statements, balance sheets, and patient volume to see whether the center is billing adequately, she says.

The AAAHC administration chapter includes a policy that the organization has implemented fiscal controls on each of the following:

— authorization and record procedures that are adequate to provide accounting controls over assets, liabilities, revenues, and expenses;

— policies and procedures for controlling accounts receivable and accounts payable and for handling cash and credit arrangements;

— rates and charges for services.

Do you have a budget?

Occasionally an AAAHC surveyor will find a facility that doesn’t have an operating budget. Nothing is planned, and there are no controls on what is spent. Instead, each year the facility turns its records over to an accountant to find out how well it did, Holmgren says. "That would be noncompliant with our standards."

Presenting thorough documentation.

Facilities should be thorough, timely, and accurate in all documentation. This includes making it easy for physicians to complete their records, says Beth A. Boyd, RN, clinical director and educational coordinator of The Breast Center in Marietta, GA. The center, which is accredited by AAAHC, is a private practice of surgeons who specialize in breast procedures.

The Breast Center’s medical records department does not wait for physicians to call and ask them to pull records on a patient who is about to undergo surgery. Instead, the center closely watches the surgery schedule and then pulls charts for the physician before being asked, she says.

Records also must be legible, says Ann Kobs, MS, RN, former director of the department of standards and current sentinel event specialist for the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.

"You wouldn’t believe how messy they can be," she notes. This does not mean the records must be on computer. But if some of your records are handwritten, you might expect that a surveyor will hand a page to an employee and ask whether the employee can read it.

Joint Commission standards about documentation include the following:

— The organization takes steps to ensure that the data are complete, reliable, valid, and accurate on an ongoing basis.

— Decision makers and other appropriate staff are educated and trained in the principles of information management.

— Information-management processes allow data and information to be combined from various sources.

— The organization uses external databases and resources as necessary to meet its information management needs.

Meeting deadlines.

Record timeliness is important, Kobs and Holmgren say. A rule of thumb is that physicians should describe the procedure on a written chart within six hours after surgery, Kobs says.

Delinquent records spell trouble

If a facility has delinquent medical records, which are records that are not completed within 30 days, this could be a problem, Kobs says. Joint Commission surveyors will ask a facility to record the average monthly delinquent records for the past four quarters.

If the total is even 2% of all records, this problem could affect the organization’s accreditation. SurgiCenter of Baltimore keeps reports up-to-date by having physicians dictate the reports by telephone.

Next, the reports are transcribed and signed, Henderson says. "If we have someone who is delinquent, then we handle that on an individual basis. But we really don’t have any trouble with that."

Facilities might want to consider electronic medical records, which are faster and have more security controls over the physician’s signature, Holmgren says. "If it’s electronic, then nobody else can apply that physician’s signature except the physician."