Compliance Issues within a Medical Surgical Unit

Compliance Issues within a Medical Surgical Unit

I. Description

A Los Angeles area hospital was faced with poor service levels, excess paperwork, and compliance issues from the misrouting of loose forms.
A Medical/Surgical Nursing Unit was piloted for developing its Healthcare Information Management System (HIMS/IDX) tools for a more automated, one point of contact setup.

II. Key Findings

• No centralized location of the patient chart information.
• Some information/paper sources were outdated or inconsistent.
• Doctors, Nurses, Therapist, etc. were having difficulty accessing the charts
(forms/paper) in a timely manner.
• High % of order delays caused by current process setup.
• Upon patient discharge/transfers, a high % of charts were identified as incomplete, causing increase in the billing cycle.
• No central source for all skilled staff orders (pending/current/historical) to identify workload at the beginning of the shift.

III. Methodology and the Road to Success

• Eliminate the “Kardex” and other redundant paperwork – some of which was
automated in LINC.
• Established a Nursing team to be the central point for IDX updates.
• Developed Skilled Staff Reports and Work lists for shiftily review which summarized the tasks required for each patient.
• Setup a concurrent review and feedback loop process for identifying incomplete charts prior to the hand-off point.
• Deduced the patient chart locations from 5 to 3 (centralize it to one point with emedical records) by automating the documents.
• Identified wireless devices for remote patient chart access (bedside charting).
• Incorporated flagging system for new orders and educated the doctors and
secretaries reducing order entry delays.

IV. Results Achieved

• Automated critical tasks and order entry into IDX, installed wireless devices and moved to one source for patient information (LINC and chart).
• Reduced redundancies and errors for orders and daily patient tasks.
• Increased visibility of the stages of each chart (new order, processed, new patient, etc.).
• Realized over $500K in savings.

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