The Audit Report Is the Easy Part
A review of a clinic or medical office usually ends with a report. It lists what was examined, the standard it was measured against, and where improvement is needed. Writing it takes care, and it is still the smaller part of the job. What decides whether the review was worth anything is what the team does with it in the months that follow.
Anyone who has run a program knows how a report like this is received. It arrives on the desk of a team that is already stretched, and the quickest way to resolve it is to correct every record in the sample and mark the corrective action complete. Everyone involved is acting in good faith. The gap tends to return anyway, because whatever produced it has not changed.
Correcting a record and correcting a process
If a review flags an unsigned note, someone gets it signed, and that one record is fixed. If unsigned notes appear throughout the sample, signing them does nothing for next month’s records. The corrective action in that case has to address the conditions: who is responsible for the signature, what prompts them, what happens when the prompt is missed, and how anyone would find out.
Corrective action plans often treat these as the same thing. They list corrections, trainings, and reissued policies, and they close each item on schedule. Completion is easy to document, but the question a plan needs to answer is whether the finding is less likely to recur, and a finished checklist cannot tell you that.
Where findings usually come from
Traced back far enough, a documentation gap often ends at the point where one person’s responsibility stopped and another’s began. The care manager assumed the coordinator would document the follow-up. The coordinator assumed it belonged in the care manager’s note. Each of them was doing the job as they understood it, which is why additional training for either one seldom solves the problem.
This is why it helps to spend time with the staff doing the work as well as the people who manage it. The front desk knows which step gets skipped when the phones are busy. A case manager knows which field in the system does not fit the cases she actually sees. That kind of information never shows up in a chart audit, and it is often the real cause. AHRQ’s guidance on root cause analysis makes the same point about looking at systems before individuals. I would add that the system in question is usually smaller than people expect. Often it is one queue, one form, or one unclear rule about who owns a step.
Three things a plan should include
A strong corrective action plan includes three things.
The first is one accountable person for each action, named individually. A department cannot be accountable in the way a person can.
The second is a date for looking again, set far enough out that the new process has had to run for a while without anyone watching it closely.
The third is a measure of effectiveness that is written down before the work begins. If the finding was late follow-up documentation, the measure should be the rate of late follow-up documentation in a new sample. Attendance at a training session does not tell us whether the problem was solved.
This third element can feel uncomfortable, because it means the plan can be shown not to have worked. It is also the most valuable part. A plan that can only succeed on paper gives the organization nothing to learn from.
The sign of a plan that is working
A strong sign is a team that runs its own recheck before anyone asks for it. Sometimes the number improves and sometimes it does not, but in either case the team can explain why. That is the mark of an organization that has started using audits for its own purposes, and it matters more than any single score in the report.
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About the author
Sherry Sayari, MPH, is an Operational Standards Evaluator who has led population health, community outreach, and social services programs. More on the About page.
