Report Card Helps Track Timing, Dating Orders

Matt Phillion, July 22, 2010

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.

Matt Phillion Matt Phillion, CSHA, is senior managing editor of Briefings on The Joint Commission and senior editorial advisor for the Association for Healthcare Accreditation Professionals (AHAP).
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