Authored by Roy G Beran
Quality Assurance (QA) measures in private practice require the collaborative effort of practitioners and their administrative staff and are designed to monitor and improve the efficiency and quality of clinical practices and patient care. The private research company ‘Strategic Health Evaluators’ (SHE) in Sydney, Australia, has developed a unique QA system based on diagnostic coding to monitor follow-up treatment for patients, report incidents and assess the appropriateness of current patient treatment. Concurrently, the system is also useful in creating a pool of potential subjects for clinical trials as patients are categorised within a database by their diagnosis. This paper reports the benefits of the application of diagnostic coding in the private practice environment and evaluates the extent to which the system has achieved its goal of quality assurance.
Introduction
Quality Assurance (QA) procedures are critical in clinical practice to ensure the highest standard of patient-oriented care [1]. To guarantee that QA measures are being conducted and adhered to by healthcare practitioners, efficient operation systems must be in place to ensure that a patient’s health, wellbeing and care are monitored, long after the patient has left the waiting room [1]. These systems aim to provide the highest quality of patient care through incident reporting and care monitoring [2,3], to reduce the risk and recurrence of errors, such as patient loss to medication errors [4], follow up, and patient non-compliance with treatment [2]. Methods of providing such QA are usually only practiced in large institutions and are usually not adopted by single practitioner clinics [5]. In large institutions, where much QA is in place, there is usually a department within the hospital which assures responsibility for monitoring and is answerable to the hospital administration rather than the clinicians who deliver patient care [6].
Strategic Health Evaluators (SHE) in Sydney, Australia, is a private research company operating in conjunction with, and as an integral component of, a single clinician community-based neurological outpatient service. Due to the limited resources available, as a result of being a small, privately owned practice, the clinic has developed a unique system of diagnostic coding to assess patient specific parameters to help monitor with patient care that is directly comparable to that of the measures offered in larger institutions. This diagnostic coding system examines patient files and identifies patients by their diagnosis, allowing for the neurologist and all staff to monitor patient treatment, compliance, communications, content of medical records and results and serves as a safeguard to prevent against medication errors and other anomalies.
The clinic, which is the subject of this review, has instigated a number of QA measures, such as writing to the referring practitioners, should a patient fail to keep an appointment without notifying the clinic. As the clinician sees approximately 100 patients per week, it is important to both maintain QA as well as undertake clinic audits to ensure that the additional demands, imposed by QA procedures, are valid and productive. Diagnostic coding requires significant time investment, work delegation and collaboration of practice staff with the objective of verifying that treatment regimens were adhered to; that the risk of medication errors was minimised; that necessary tests have been performed; patient compliance was maintained with proper follow up ensured; and that correspondence between specialists, general practitioners and carers was complete.
Being a research company, the diagnostic coding system not only serves to provide a means for effective QA but also aids in the clinical trial recruitment process by identifying a possible source of trial candidates, found to have specific diagnoses. The purpose of this paper is to determine if the time, collaborative effort and resources, necessary to conduct diagnostic coding and QA, was of sufficient benefit to the practice and its patients to justify continuing the process, and, if so, to what extent has it satisfied the goal of QA.
Methods
At SHE, patients who attend the practice are assigned a medical reference number (MRN), numerical in sequential order, similar to the procedure adopted in much larger institutions. All medical documents related to a patient are filed into that patient’s medical record using their MRN as an identifier, as patient records are filed by number rather than alphabetically. During diagnostic coding, 50 recent patient files are selected and offered for review for every 50- 60 new patients that are seen at the clinic. The files are selected based on MRN, in sequential lots of 50, leaving a gap of 100-150 files (MRN numbers) between the newest patient to the practice (who will have the highest MRN), and the first MRN in that set of diagnostic coding files. For example, if the newest patient’s MRN is 2000, the diagnostic coding process will begin with MRN 1850 and end in MRN 1900, and after seeing 50 new patients (namely, the last seen will have MRN 2050), the next diagnostic coding set of 550 will begin with MRN 1900 and the last MRN will be 1950). The purpose of leaving this gap, between the latest patient and the start of the diagnostic coding set, is to allow for follow up material (such as letters and results) to be received by the practice and to allow for sufficient time to establish a better working diagnosis or for necessary tests to be performed. It also overcomes some logistic problems that may delay certain tests to be performed, such as in-patient polysomnography, as the clinician is also an accredited sleep physician.
Should a follow up letter be required, consequent to review of the patient’s record, the neurologist will dictate such a letter, which will be sent to the relevant recipient- which may be a general practitioner, an authority such as the driver licensing authority, a caregiver or another referring doctor and, where appropriate, copied to the patient. Patients with particular medical conditions or diseases will have these diagnoses coded and the files noted by said diagnosis, for future reference. This confirms that the file has been reviewed and allows for ease of access, should research focus on that medical condition. If a patient’s file needs to be accessed by the neurologist or a staff member, dependent on their diagnoses, the diagnosis is entered into the system and the MRN’s of all patients with that diagnosis will appear.
Diagnostic coding requires specific time allocation - the neurologist will require 1.5 hours on average to review 50 files and complete any necessary dictations, or institute follow up procedures, whilst concurrently recording the diagnosis. The medical typist will require 2-3 hours to produce appropriate correspondence as required and to document diagnostically coded patients by their MRN with diagnostic categories. Responses from patients, healthcare specialists, caregivers and authorities are monitored by the neurologist and the office staff to ensure that all recommended follow up procedures are performed. The process requires a significant amount of invested time by all concerned.
If, at the time of coding, a patient’s file is unavailable, due to the patient having an appointment and their file allocated for a consultation, diagnostic coding will need to occur following that consultation. This may necessitate extra time per patient depending on the complexity of the tasks involved, such as making a diagnosis, entering new codes electronically and preparing a follow up letter (if needed).
If action is required by the patient, as a consequence of the diagnostic coding having identified a deficiency, such as having a test performed before resuming driving, this is notified to the referring doctor, and with the correspondence copied to the patient. Office staff maintains a separate record of such correspondence to ensure compliance and, should there be no response, then follow up action, such as notifying driving authorities, ensues.
Results
Between the 1st of May 2013 and the 13th of April 2016, patient files 19951-21450 inclusive, and file 13842 were reviewed for diagnostic coding. Of the 1501 patient files reviewed, 1263 (84.1%) required no further action after coding, whilst the remaining 238 patients (15.9%) required a follow up letter. During our review, no medical errors or other anomalies were noted and no medication revisions were required. Thirty two of the 238 letters sent were regarding fitness to drive assessments; more than half (20/32) required further correspondence to the Roads and Maritime Services attesting a lack of fitness to drive, eight required no further action due to appropriate follow-up having taken place, and four patients were lost to follow up regarding driving fitness.
Thirty of the 238 letters regarded follow up of results, reminders or cancellations of Magnetic Resonance Imaging, Electroencephalograms, polysomnographs, and/or CPAP titrations, including 14 patients who did not attend their appointments, cancelled their appointments or failed to follow through with clinical advice. Correspondence was returned by the GP of one patient to inform the practice that the patient had since died. Ten letters indicated that the patient was under the care of another specialist and did not need to return to the practice. Other patients had failed to keep follow up appointments at the practice, failed to have necessary tests performed, had been ordered therapy with no indication of success (or otherwise) and left doubt that proper care had been provided. Many letters simply sought feedback to ensure that the patient was receiving appropriate care.
Three potential trial candidates were able to be identified by the trial coordinator using the diagnostic coding categories and were subsequently screened for inclusion into the suitable trials.
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