Managing Your Practice
Advisory No. 9

A quality improvement program for an office practice

• Three parts to an effective QI program
• Part I: Ongoing management of the quality of patient care
• Part II: Monitor adverse outcomes
• Part III: Random chart review
• Get advice from MIEC
• Form I: Quality Improvement Event Tracking Form
• Form II: Documentation Review Self-Assessment
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Implementing a quality improvement (QI) program helps physicians demonstrate the quality of the care and treatment they provide to patients: (1) in a market of increased competition due to the changing nature of medical practices and groups; (2) as members of managed care panels whose accreditation organizations require evidence of quality care; (3) as they are scrutinized by state and federal agencies who are concerned about Medicare/ Medicaid fraud and abuse; (4) as the media focuses on medicine and physicians; (5) in an age where patients are using complementary and alternative medicines to supplement and/or replace traditional medicine; and (6) to provide the type of evidence that is essential to a physician’s defense in a medical malpractice lawsuit.

“But I don’t have time to develop a QI program!”

Your staff can help. Office staff is an integral part of the medical practice’s program to improve and maintain the quality of patient care. An office staff member who assists you to monitor the quality of medical care can be a nurse, physician assistant, nurse practitioner, certified medical assistant, or other experienced individual who understands medical terminology and who is familiar with your practice.

Three parts to an effective QI program

Part I:  Ongoing management of the quality of patient care and documentation of that care. 

Every day before each patient comes to the office for his/her scheduled appointment, the staff member reviews the charts to ensure (1) allergy and medication (including refills) information is current; (2) ordered test results have been received, initialed by you as evidence of your review, and filed in the chart; (3) the reports of referrals to specialists have been received, reviewed by you, initialed, and filed; (4) and issues pending from the last visit are flagged to remind you that follow-up action is needed. If ordered tests results or reports from specialists have not been received, the staff member should determine if the patient had the test done or saw the specialist, and if so, why the results or reports were not received. Time is wasted if the patient’s follow-up visit is for the purpose of reviewing and discussing test results that are not available.

After each patient has been seen, the staff member reviews the chart to ensure the doctor has documented: (1) a return visit date; (2) the reasons for ordered medications, tests and/or referrals; (3) the patient’s medical problems and a treatment plan; (4) evidence of oral and written patient education; (5) when a follow-up appointment is needed. The doctor can flag certain charts for a next-day call back. (Selected patients are called by a staff member who asks, on the doctor’s behalf, how the patient is doing; if the patient any questions; if a prescription was filled. Patients like these calls. Equally important, they may provide indications that some of the patient’s questions were not answered or identify a post-treatment problem the doctor should know about.) In addition, the staff member can: (a) calendar for follow-up all ordered lab tests or referrals to a specialist; (b) check that the doctor has documented the name, drug, dose, and amount of prescribed or refilled medications; (c) make and document the follow-up calls the doctor has requested. For surgical patients, the staff member can check that the doctor has documented that the patient received preoperative information and instructions; and, when appropriate, that the doctor documented an informed consent discussion with the patient in the progress note. 

Part II:  Monitor adverse outcomes in the medical practice. 

Establish a list of potential adverse outcome indicators related to your practice. Some examples: (1) adverse drug reactions; (2) extended drug therapy with no improvement; (3) injury during an office procedure; (4) missed or delayed diagnosis; (5) sudden demise of a patient; (6) unexpected exacerbation of patient condition; (7) emergency department visit for a medical problem for which you are treating the patient; (8) overlooked abnormal pathology, laboratory or X-ray studies; (9) unreasonable delay in resolution of a medical problem; and (10) other criteria you choose.

When the day’s charts are reviewed, the staff member sets aside for the doctor’s review those cases that match one or more adverse outcome indicators. To expedite the review, the staff member tags relevant pages in the chart and attaches a QI Event Tracking form (See Form I), marking on the form which matching screening criteria apply. After the doctor has reviewed the set-aside charts, he or she completes the tracking form and documents what follow-up is needed (e.g., call an MIEC claims representative for advice; calendar the case for a re-review; refer the case for group discussion with colleagues). The staff member follows up on the doctor’s requests. The staff member keeps a log of the matched screening criteria and subsequent action taken. The log identifies important information about the types of adverse outcomes that continue to occur in the practice and require the doctor’s attention.

Part III:  Random chart review for documentation deficiencies. 

Each week (or month), the staff member selects at random ten or more current patients’ charts for the doctor’s review. (Form II can be photocopied and used to document these reviews. The items listed are discussed in MIEC’s Medical Record Documentation for Patient Safety and Physician Defensibility: A Handbook for Physicians and Medical Office Staff on the pages shown in the parentheses on Form II.) In some medical practices, the staff member can do an initial screening using the documentation criteria on the form; the staff member sets aside charts that do not meet the listed criteria so that the physician can review them. The results of the periodic screenings can be tracked over time and discussed at formal or informal meetings of the practice’s physicians.

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