Report Card Helps Track Timing, Dating Orders

Shelia Hull, RN, Joint Commission specialist with Pikeville Medical Center, Pikeville, KY, was with the organization just a few months before the latest PPR was due to The Joint Commission. At that time, she and her supervisor discovered the organization had fallen out of compliance with its timing and dating of physician orders.

“We were trying to come up with ways to achieve better compliance in this area,” says Hull. “We already had reminders at the documentation areas on each floor.”

The organization also had a program for brightly colored reminders for all entries to remind physicians about timing and dating. And yet, they still were not meeting the organization’s expectations.

It was time to expand to other methods.

They began with the CMO: she listened to the expectations the organization was hoping to meet and began addressing it at staff meetings. But this was a stopgap measure. It was an idea from the stroke manager in Pikeville’s ED that brought the process up a notch.

“The ED stroke manager said we needed to give them something like a report card, show them how well they’re doing,” says Hull.

Pikeville went with a color-coded system for demonstrating compliance:

• 90-100%: green
• 70-89%: yellow
• Under 70%: red

“We had it broken down into what components they were missing,” says Hull.

Hull worked to do 70 chart reviews each month, followed by report cards for each.

“When the program started we weren’t where we should have been,” says Hull. “I think this was effective in getting their attention—I had calls from physicians who wanted to talk with me to explain what they needed to do to improve on where they were falling out of compliance.”

This increased awareness has brought about a marked improvement in timing and dating compliance.

The improvements were palpable just in terms of percentages: Pikeville began at 40% compliance and climbed quickly to 78% compliance. The goal, says Hull, is 90% at a minimum.

“We aren’t where we want to be yet, but it’s a steady improvement,” says Hull.

Positive reinforcement

It’s one thing to tell physicians when they are out of compliance; it’s another to do so without recognizing good work as well. To counter this, Pikeville also instituted a recognition program for those who remain “in the green” with timing and dating.

“We call it the 90-Plus Compliance Club,” says Hull.

This list of top performers is posted throughout the facility and is published regularly in the organizational newsletter. It is also sent to the CMO directly.

“It’s just a chance to congratulate them,” says Hull.

Still, improving compliance is a slow process—getting the right combination of communication and motivation. Physicians seem to be reacting well to the process, though.

“I take it when they contact me that they are looking to improve, otherwise they wouldn’t reach out,” says Hull. “I’ve had some contact me to say they thought they were doing better than they are, and that this made them more aware.”

Of course there will always be those who fight the process and remain non-compliant, but the vast majority took the report cards to heart.

Developing the form

In order to create the report card, Hull listened to “listserv chatter,” she says, in places like AHAP Talk, and found a wide range of ideas. Pikeville’s director of stroke crafted a report card of her own which would serve as the basis for the form now used at the facility.

“I discussed it with my supervisor, then with the vice-president, and then talked it over with the CMO,” says Hull. “We then put out what we were developing to each director so everyone was aware, and then sent out a letter to every physician.”

To put some weight behind the decision, this letter quoted not only Joint Commission standards on timing and dating of physician orders but also CMS requirements.

“We wanted to explain ahead of time” so as not to catch them off-guard, says Hull.

Next step

The next course of action is to continue preparing for Pikeville’s upcoming survey—including timing and dating of orders.

“What we’re doing is having the unit secretaries or nurses pull their orders to see what has or hasn’t been timed. The challenge right now is timing, not dating—our physicians are very compliant with dates. Timing remains a challenge.”

When a unit sees they have an issue with failing to time and order, they attempt to catch the physician while he is still on the unit to rectify the issue. If the physician has already moved on, they flag the record.

Another area being worked on is the electric time and date stamp. Pikeville is in the process of converting over to a completely electronic order submission program.

“We haven’t got there yet, but it’s just a process of getting it into place,” says Hull. “It takes a lot of time and training.”

It’s really about perseverance more than anything, she says.

“Stick to your guns. When you audit and see that physicians aren’t complying we need to bring that to their attention,” says Hull.

Get the idea, the concept for communication, and work your way through each individual department. Find out what time physicians make the rounds, and try to meet them on their unit face to face.

“I like to do things in person,” says Hull. “But being in person with hundreds of physicians can be nearly impossible. Still, I make every effort to meet them one on one. I think they perceive me better when we speak face to face rather than receiving a letter.”

In the cases where a face to face just can’t happen, Hull will personalize the letter to the physician to make the importance of what she’s asking as clear as possible.

Tone matters too.

“I always talk to the physician like I would with a good colleague or good friend. I try not to point fingers or embarrass anyone,” says Hull. “As long as you’ve got your facts with you to explain why you’re having this discussion, you’ll be fine.”

Those facts are invaluable. Physicians are known to prefer hard data when being asked to change methods or behavior, and having percentages of timing and dating orders to back up your statements is a must.