Journal of Medical Systems, Vol. 15, No. 2, 1991
Quality Assurance Tracking or "Finding the Needle in a Haystack" Anthony B. Kirtland
This paper will present a picture of the steps required from conception, through development, and leading to implementation of an automated Quality Assurance Incident Tracking System within in a multihospital system utilizing general purpose software (WordPerfect and Lotus Agenda). This automated tracking system provides the manager with an effective and efficient method to control multiple staff assignments, tasks, and manage multiple objectives over the resolution cycle associated with hospital incident reporting in the Quality Assurance arena. It also provides the QA managers and hospital executives with an individualized record of the Incident's progress and helps identify useful and dysfunctional patterns in the resolution of the Incident. The identification of these patterns can assist hospital management in revising and developing protocols and procedures that minimize hospital exposure to state sanctions and provide a mechanism to improve the quality of care in the institution: QA Tracking, Quality Assurance, Incident, Automated Tracking.
PROBLEM STATEMENT In New York State and in other highly regulated states when a reportable incident occurs, a 45-day-clock starts for Hospital Management to determine the cause and to develop a solution to correct this problem in the future. The risks associated with the hospital's failure to comply are: fines, focused reviews, restriction or loss of licensure, and adverse press releases regarding this information. The process for handling a reportable incident requires the interaction of multiple people and departments in a coordinated fashion to complete the tasks. The process demands that one individual, the Quality Assurance Manager (QA Manager), be responsible for the completion of these tasks. In addition, it is expected that at least one incident occurs daily. The ability to manage this process manually is almost impossible. The system to accomplish these tasks is disjointed, unorganized, and prone to failure.
MATERIALS AND METHODS The tasks presented to us are to improve the control and the knowledge of the status of an incident, the timeliness, to provide continuing documentation, and to minimize exposure to state sanctions. The first step in the project is to document the process flow that an incident follows to resolution, and to identify bottlenecks or delays in the system. From the SunHealth Alliance at Peninsula General Hospital Medical Center, Salisbury, Maryland 21801. 183 0148-5598/91/0400-0183506.50/0 © 1991 Plenum Publishing Corporation
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Kirtland
DYe-5 Incident Occtues
/
%.
Hosp IqgP investigates for Uerbal
Rpt
QA ~ investigates for Uerbal ~t
Hosptial Hge cal~s state gives Uerbal
QA Hgecalls state gives Oerbal Rpt
v i t h i n 2 to 3 dags.
gepba/ b t archived.
~t
no~tfle4
Ue~bal Rpt apchived.
a s s 1 ~nls
Incident to QA StaJ'ter 81.
I Figure 1. Original process flow.
185
Quality Assurance Tracking
QA Staffer |1 collects in£or~ation for the DIR eet
DIR key Rpt data
I
entered.
I I
DIR isI~ QA proofed Stafferll
QA Ng~ to get SenioP Admn signature on IR npt.
l
./,,X\ .//~enio~'~
/ A(INin \ n v (,~ Available? . /
+\
+
~ i t for 5i~at~ Mmin
f~om Senior
// Get ethe~ SenioP Admin to s i ~ ,
Get signature
and send to state.
Figure 1. Continued.
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Kirtlnd
DY_6-45 QA Stat'fee |Z requests Ned Rec seaech foe inroz~mation.
Ned Aec S t ~ f ?ull eecoc~Ls.
QA s t ~ f e e 112 conducts a detailed seaech foe information.
QA s t d r e e 81 collects i n f o ~ t i o n t~om QA s t ~ f e e 02 to complete the ~ R l~pt,
l is Ice entered into the system.
roe •ArinCed st~tee |1.
[ Figure 1. Continued.
Quality Assurance Tracking
l
QA s t ~ f e r 81 schedules case f o r next comittee neeting,
Conni ttee r e v i e ~ the case and r~COnl~flds an action.
gl St~ffe~ I1 ciocuMnts comi t tee action in FA
ppt
FJ ~pt is entered inte the sgsten
Avait s t a t e audit and action. Figure 1. Continued.
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Kirtland
Then, system changes are developed to eliminate the bottle-necks. The last component is to design an automated tracking system to improve the control and the quality of the information available about the individual cases. The documentation of the original process flow (Figure 1) shows that 32 steps involving six departments are required to complete the processing of a Quality Assurance Incident. The problem areas identified in the original process flow are: 1. The reporting of an Incident to the State is not assigned to a specific individual in the hospital administration. This causes problems involving the correct reporting format, type of incidents reported, and timeliness of notification. 2. The lack of a clearly defined procedure to obtain senior management endorsement of the Incident Report in a prompt fashion causes unnecessary delays. 3. The Quality Assurance manager could not reliably track the status or level of completion of the QA Incident through the system. 4. The QA Incident resolution is delayed if any step in the process is missed or incomplete. 5. There are no expected completion dates for critical components in the process. 6. Completion of all tasks occurred only when an incident is expedited through the system. 7. Improvements to the system could not involve large dollar expenditures, a significant amount of training, or a staffing increase. Once these system constraints are identified, the next step is to revise the processes to improve the outcomes and minimize the fault potential. The following are system improvements designed to correct process problems. 1. Revise and streamline the process flow from 32 to 22 steps and from six to four departments (Figure 2). These changes improved the control over the activities necessary to resolve the Quality Incident. 2. Specific time limits are established for the completion of critical steps in the process (Figure 2). This gave all the participants goals for completing each phase of the process. 3. The outcomes for each critical step are defined by the participant, the task, and the date of completion. 4. A tracking system is developed using two generic software programs Wordperfect and Lotus Agenda. The wordprocessing software Wordperfect is selected because it is readily available in the department and requires no training in its use. In addition, creating the Incident Template, which lists of all activities, participants, and step completion dates, is a natural progression of the mail-merge function. Lotus Agenda is selected because it is easy to use, adaptable, and its capability a "Context Sensitive" database. This feature in particular allows the user to enter information without forming the database structure In'st. The software allows reconfiguring of the structure of the database at any time as new patterns emerge. Other project management softwares were examined and not selected because of the cost, the learning time required to become proficient, and the capabilities of the software exceeded the needs of the task. With the software platform identified the internal components of the Tracking System are developed to meet the needs of the QA Manager and Senior Administration to
189
Quality Assurance Tracking
D~Y_L
QA ttanager gathers the infemation for the verbal eepert ASAP.
l
QA Manager ~ v i e v s the verbal report infoeuation.
QA ILmager contact' S state and gives verbal report.
QA Kanager assigns the Incident investigation to staff ke~dmer01
b
UerMl I ~ o r t in(nauatlon key ente~d into r~ system.
(
Figure 2. Revised process flow.
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KirtJand
mYS..J.-3 Ot St~ftor | i gatheps detailed infornation fop the Plt ~ e r t
IR r~poat is genented
DIRr, el~rt data is key entePed into the system.
QA staLffeP |1 pcoofs the IR report.
~Y_5 qA Nanager obtains IB ael~rt iad.~ets Adninis~Pative Signatu~.
QR office staff sends the IR ~eport to the State. Figure 2. Continued.
Quality AssuranceTracking
191
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QA staftep 12 conducts detailed search of mdicaJ ~co~ls (or (omation.
~t_J.8 QA s t d f e r !1 takes in(o].nation gathe~,d bg sta~(er 12 and conpletes the ~CR ~e]~t
CR Report is printed and given to QA staffee | l .
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incident (oP reviev be(o],e the apl~opriate ,wdical comittee
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DY~L-34
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¢onni tree ~vievs the case and takes actions.
i
)CR
intornation i s key . eft TePed i n t o the systen.
Figure2. Continued.
Kirtland
192
1
U Staff | I takes Comittee xinutes and ©expletes t~e IrA eel:oPt
~_35-45 IrA eepos.ts f i l e d as to actions taken.
~ltJs÷ h a l t state audit of actions. Figure 2. Continued.
control the processes. The first component is to develop the activities' template statements, which lists the key steps, the participants, the expected outcomes, and the completion dates. The mail-merge function in Wordperfect allows the user to create a series of statement patterns with "blank" fields. The fields are used to identify the case number, the participant, and the completion time for the key steps. Using the template allows the QA manager to assign the participants based upon individual expertise, department workload, and time constraints. The "mail-merge" function creates a listing of the tasks needed to complete the investigation of the Quality Assurance Incident. The document file is imported into Agenda which converts the file into a series of ITEMS that Agenda can enter into its "Context-Sensitive" database. Agenda uses the structured files to convert the Incident Data it into an information database capable of tracking incidents, assignments, people, and dates for each step. From this point forward the database becomes a tracking system, which monitors the completion of the Quality Assurance Incident. The tracking is done by examining the data through a series of screens called " V I E W S . " A VIEW a subset of the database using critical information to define categories and sections. For example if the QA Manager wants to see all the steps associated with a particular incident he selects the Task List View (Figure 3) which sorts the database on the criteria of the incident, the participants involved in the step, the completion date, and the step designator. This same database can produce a Case Assignment View which sorts on the criteria of the participant, completion date, case and step specific tasks, and the completed report tasks (Figure 4). The database can be sorted another way to produce the Assignments Next Day View which sorts on the criteria of tasks to be completed the next day, the participant(s), the Reports required, and case and step designators. Each of
Quality Assurance Tracking
193
91142
Who
When
Step
*
1 Case 91142 step A1 Kathy gathers VR report data 1 day from 5/06/91.
-Kathy
-05/07/91
.AI
*
2 Case 91142 step A2 Kathy reviews VR report data 1 day from 5/06/91.
-Kathy
-05/07/91
.A2
*
3 Case 91142 step A3 Kathy phones OHSM with VR report data 1 day from 5/06/91.
-Kathy
.05/07/91
.A3
*
4 Case 91142 step A4 Kathy assigns ease to Elizabeth 1 day from 5/06/91.
.Elizab
.05/07/91
-A4
*
5 Case 91142 step A5 Karen key enters VR report data 2 days from 5/06/91.
.Karen
.05/08/91
.AS
*
6 Case 91142 step A6 Elizabeth gathers DIR report data 3 days from 5/06/91.
-Elizab
.05/09/91
-A6
*
7 Case 91142 step A7 Karen key enters DIR report data 3 days from 5/06/91.
-Karen
-05/09/91
-A7
*
8 Case 91142 step A8 Elizabeth proofs I R report data 4 days from 5/06/91.
-Elizab
-05/10/91
.AS
*
9 Case 91142 step A9 Kathy obtains IR report and ASG signature from Joe 5 days from 5/06/91.
.Joe
.05/11/91
-A9
*
i0 Case 91142 step AIO Karen mails IR report to OHSM 5 days from 5/06/91.
.Karen
.05/11/91
-AIO
*
II Case 91142 step All Bill orders MED REC report 5 days from 5/06/91.
.05/11/91
-All
~gure3. Task List View.
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Kirtland
12 Case 91142 step AI2 Mary MR department pulls MED REC report 7 days from 5/06/91.
•Mary
.05/13/91
.AI2
*
13 Case
•Elizab
.05/15/91
.A13"
*
14 Case 91142 step A14 Karen key enters DCR report 18 days from 5/06/91.
-Karen
-05/24/91
.A14
*
15 Case 91142 step A15 Karen prints Preliminary CR Report which is proofread by Elizabeth 20 days from 5/06/91.
•Elizab
.05/26/91
-AI5
*
16 Case 91142 step A16 Elizabeth schedules ease on next Surgical Committee meeting, 21 days from 5/06/91.
•Elizab
-05/27/91
-A16
*
17 Case 91142 step AI7 Karen files FA Report 35 days from 5/06/91.
•Karen
-06/10/91
-A17
*
18 Case 91142 step AI8 Karen purges VR Report data from PC 45 days from 5/06/91.
•Karen
.06/20/91
..AI8
91142 step AI3 Elizabeth transcribes DCR report 9 days from 5/06/91.
Figure 3. Continued.
Quality Assurance Tracking
195
Julia
When
Case
Step
RPT
*
1 Case 91143 step A5 Julia key enters VR report data 2 days from 5/07/91.
"05/09/9
-91143
"AS
-VR
*
2 Case 91143 step A7 Julia key enters DIR report d a t a 3 days from 5/07/91.
.05/10/9
-91143
-A7
-DIR
*
3 Case 91143 step AIO Julia mails IR report to OHSM 5 days from 5/07/91.
-05/12/9
-91143
oAIO
.IR
*
4 Case 91143 step AI4 Julia key enters DCR report 16 days from 5/07/91.
-05/25/9
-91143
-AI4
.DCR
*
5 Case 91143 step AI7 Julia files FA Report 35 days from 5/07/91.
-06/11/9
.91143
-AI7
-FA
*
6 Case 91143 step AI8 Julia purges VR Report data from PC 45 days from 5/07/91.
-06/21/9
-91143
-AI8
,VR
Figure 4. Case Assignment View.
these views allows the manager to examine different facets of the system to make informed decisions. The tracking function is enhanced by entering additional data to database as changes occur. Items are marked as done and removed from the database as each step is completed. Changes to completion dates and subsequent reasons can be documented immediately. This information allows the QA manager to identify task road blocks by comparing the completion date to the current date. Another useful feature of Agenda is the note capability. This gives the manager a written chronology of additional background information about problem areas for each item. Using this function aids in identifying dysfunctional patterns before they become large problems. Other features of Agenda not discussed in this paper are: reconstruction of the database from completed items, report production, and calculations which are useful in managing this or any database.
Kirtland
196
Susan
When
Case
Step
RPT
*
1 Case 91143 step A4 Kathy assigns case to Susan 1 day from 5/07/91.
-05/08/9
-91143
"A4
*
2 Case 91143 step A6 Susan gathers DIR report data 3 days from 5/07/91.
-05/10/9
-91143
.A6
-DIR
*
3 Case 91143 step A8 Susan proofs IR report data 4 days from 5/07/91.
.05/11/9
-91143
-AS
.IR
*
4 Case 91143 step AI3 Susan transcribes DCR report 9 days from 5/07/91.
"05/16/9
-91143 -AI3
-DCR
*
5 Case 91143 step AI5 Julia prints Preliminary CR Report which is proofread by Susan 20 days from 5/07/91.
-05/27/9
-91143
-AI5
-CR
*
6 Case 91143 step AI6 Susan schedules case on next Ortho Committee meeting, 21 days from 5/07/91.
.05/28/9
.91143
-AI6
Figure 4. Continued.
CONCLUSION Using these methods proves it is possible to organize multiple tasks, participants, and due dates, and track the progression through to completion. These objectives can be done without using expensive resources or increasing staff. In addition, the tracking system is designed using generic wordprocessors and context sensitive database softwares. Finally, this process has many applications' outside the arena of Quality Assurance Incident tracking and it can be cloned.
