Volume 2

Using Measurement to Design Follow-Up Training

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There are two primary methods for measuring the quality of clinical documentation: audits of documentation practices and retesting of physicians on documentation concepts and principles. The first, audits of documentation, is the most reliable, but requires a sizeable amount of staff time to perform. The second, retesting, is less reliable than audits, but requires time from the physician to complete. Either or both methodologies can be worked into your program. Follow up training has the greatest impact if it is designed to target identified weaknesses in the system.  Specifically, these are weaknesses or deficiencies of individual physicians or groups of physicians.  Focusing on specific issues is an efficient use of everyone’s time.

This chapter describes implementation suggestions that you can use to obtain support for additional resources needed. Among them, is tying your measurement efforts back to the values, vision and mission statement (VVMS) for your organization’s clinical documentation program. Your clinical documentation quality VVMS, should tie in directly to your organization’s overall vision and mission. By making these connections, you are more likely to obtain support for additional resources. You are also more apt to be successful with your efforts by showing a positive impact—one measured by your organization’s VVMS.

Chapter 11 describes the preferred primary measurement processes of documentation audits and testing. A secondary method for measurement is operational measures used in the day-to-day clinical documentation program. These may be measures like query rates, response rates, and agreement rates, among others. These measures are best used to determine the success of the program operations, not the quality of the documentation. In the interest of time savings, some organizations may use these measures to determine both quality and operations success. While not recommended, if resource constraints require using this method, you should be aware of its limitations. These are discussed in further detail in chapter 11.