Q: How does Academy Orthopedics ensure its quality improvement program meets AAAHC standards?
Karen Bennett: A part of our quality improvement program is our peer review process, which is done on a quarterly basis. What we’ll do is have members of each department review their peers’ medical charts to see if there were any problem areas and make sure they were filled out correctly. For example, one anesthesiologist’s charts will be looked over by the other anesthesiologists to make sure that anesthesiologist did an immediate evaluation of each patient before their procedure, which is required by CMS. The evaluation has to be documented in the notes, and that anesthesiologist’s peers will check how often they did that.
We take those peer reviews, look to see if there were any particular trends — such as whether a physician had frequent episodes where a patient had hypothermia in the OR, did not recognizing a pre-existing condition with the patient or had a complication with administering medication— and assign each chart with a score. This way, we can make sure if there is a recurring problem, we can identify it and come to a resolution on how to prevent that issue from happening again.
Q: What other procedures are in place to help with quality improvement?
KB: We also do an occurrence report, which gives me an immediate notification of an incident without having to wait to identify the problem until the next quarter. An occurrence report is a simple sheet passed around to physicians. It’s a checklist that lists things like “incomplete history and physical exam,” “injury to patient,” “cardiac or respiratory arrest,” “equipment problems” and so on. All those problems are identified quickly so that it can be addressed immediately.
The board is also an integral part of it because all the reviews and reports go to them as well. They are directly involved with the handling of these issues and coming to a resolution on how to handle them. After they review the reports and any chart reviews that received a poor score, they may say that we need to re-educate or train the staff on policies and procedures or change a process because it wasn’t good the way we had it. For example, if we found we had three patients who were late for their appointment, we’ll look at their charts to see what time they were instructed to come in and if they were properly instructed by the staff. The board may say that we need to change the way we instruct patients from mailing instructions to talking to the patients instead.
Learn more about Academy Orthopedics.
