Title: Evolution of a Formal Document Integrity Program
Presenters: Sheila Guston, CHDS, AHDI-F; Christine Tyrrell; Stacy Lehto, CHDS
Date: October 19, 2016
Time: 10 a.m. Pacific/1 p.m. Eastern
CEC: 1 MTT
Regular List Price: $25
Regular Eligible Member Price: $15
This session describes the high rate of errors found in clinician-created documentation today. The types of errors found and root causes of those errors reinforce the critical need for a formal quality assessment program in clinician-created documentation. Spectrum Health (AHDI Employer of the Year 2011) has developed such a program based on the Resource Kit created by AHDI and AHIMA, Clinician-Created Documentation: Reinstating Quality Assurance Programs to Safeguard Patients and Providers. In partnership with Christine Tyrrell, President of Tyrrell Software, LLC (and AHDI’s 2011 Innovation through Technology Award Winner for TQAudit), they have created a system of quality management that allows them to measure, collect, report, analyze, track, and trend data, as well as improve clinician-created documentation. With the implementation of TQAudit, Spectrum Health is now able to use the data they have collected to accomplish their primary goals—educate providers and improve documentation while keeping patients safe.
- Recognize the high rate of errors in clinician-created documentation.
- Acknowledge the critical need for quality assessment programs in clinician-created documentation.
- Learn about the evolution of Spectrum Health’s Document Integrity program.
- Learn how TQAudit, a data management tool traditionally used for traditional transcription quality reviews, is being used for clinician-created documentation integrity audits.
Sheila Guston holds a Bachelor of Arts degree from Vassar College in Poughkeepsie, NY. She is 2015-2016 President-elect for AHDI and has served on their Manager/Supervisor Alliance for the past few years. Sheila is Supervisor of HIM Document Integrity and Coordinator of Dragon Implementation and Training at Spectrum Health in Grand Rapids, MI.
Christine Tyrrell holds a B.A. in Mathematics and an M.S. in Computer Science, She has been an avid software developer throughout her career, in many high tech fields including aircraft avionics and simulation, and financial/management arenas. Christine has been committed to the healthcare documentation community since 2006, when TQAudit was first developed. Since then, she has been passionate about patient safety, collaborating with her clients to meet their QA goals, and participating in and contributing to several AHDI quality initiatives. Her business, Tyrrell Software, LLC, is proud to be a corporate member of AHDI.
Stacy Lehto, CHDS, has been in the medical transcription field for 17 years. She has done transcription, QA, and has also been a QA auditor. She is currently the Quality Coordinator for Documentation Integrity at Spectrum Health. Stacy has contributed to AHDI’s e-book on Strategic and Business Planning Skills and has been instrumental in the development of the toolkit Clinician Created Documentation: Reinstating Quality Assurance Programs to Safeguard Patients and Providers. Stacy has worked as copy editor for several of Stedman’s word books, including their Medical Transcription Skill Builder series.