Topics in health record management最新文献

Organizationwide quality improvement has offered many organizations in many different industries a new approach to work and leadership. The lessons learned can be applied to the health care setting. QA professionals can play an important role in this change by leading through example--first in their own departments and the work they currently perform and then throughout the entire organization.

Trustees do not seem to agree on how quality accountability will be accomplished, but they are starting to agree that procedures to establish quality accountability are necessary. They also agree that leadership from the board level, coupled with a firm resolve to monitor quality, will ensure that hospitals provide high-quality care and services to their most important and influential customers: patients. The manufacturing industry has provided the health care industry with the benefit of its experiences with continuous quality improvement, including the pitfalls. It is both exciting and challenging to learn the philosophies of total quality management and build a customized strategy for excellence, especially in medical record departments. As a customer of numerous processes throughout the health care organization and a supplier of products and services as well, the MRD represents a common thread throughout the organization, often linking people and departments together. A medical record professional who is working in a health care organization whose executives believe in TQM can expect great things in the decade ahead.

Customer knowledge is an essential feature of hospitalwide quality improvement. All systems and processes have customers. The aim is to use customer knowledge and voice of the customer measurement to plan, design, improve, and monitor these systems and processes continuously. In this way, the hospital stands the best chance of meeting customers' needs and, hopefully, delivering services that are so outstanding that customers will be surprised and delighted. There are many methods, both soft and hard, that can be used to increase customer knowledge. One useful strategy is to use a family of quality measures that reflect the voice of the customer. These measures can generate practical and powerful customer knowledge information that is essential to performing strategic planning, deploying quality policy, designing new services, finding targets for improvements, and monitoring those continuous improvements based on customers' judgments.

These suggestions for applications of QI philosophies and considerations for structural integration of QA and QI are not intended to convey that organizationwide adoption of QI merely involves use of QI tools and techniques, or that instilling QI philosophy in an organization is easily accomplished. Achieving continuous quality improvement on an organizationwide basis requires long-term, senior-level commitment, extensive training, adoption of the philosophies at all management levels, and behavioral and cultural change within the organization. The adoption of QI methods and philosophies in health care organizations does not preclude the use of or eliminate the need for QA approaches. Quality improvement and quality assurance are complementary endeavors for attaining continual improvement in health care quality. Improvement of the quality of care provided is and always has been the fundamental goal of health care quality assurance. Attainment of that goal can be advanced through building on the strengths of traditional quality assurance efforts and adopting philosophies and methods of quality improvement as the core forces of total quality management programs.

TIMY is the ideal management system for novice data-entry personnel as well as for the research staff, nurses, and physicians at our facility. Access to data through the use of menus and security systems makes TIMY a user-friendly database. It has excellent data export capabilities so that more complex data analysis can be performed using dedicated software such as SPSS/PC, BMDP, or SAS. This provides great flexibility as well as the power needed for the study of complex data sets.

The Pennsylvania Trauma Systems Foundation has existed for five years. A concept that in 1984 seemed like a futuristic dream has been accomplished. Standards for trauma center accreditation have been developed, and trauma centers are accredited in a fair, unbiased, and systematic manner. Pennsylvania's voluntary system could not have succeeded without the full support of the hospital, medical, and nursing communities. Trauma centers are not edifices alone; the commitment of the institutions and their personnel was phenomenal. Pennsylvania has the largest and most comprehensive trauma registry in terms of complete data compliance in the United States. Data collected have been used for quality assurance, the accreditation process, and trauma prevention and research. The commitment by medical record professionals to develop and maintain individual hospital trauma registries as well as the PTSF trauma registry has been enormous. The future of trauma system development in Pennsylvania lies in the data collection system and the research in trauma systems and trauma care that is generated from the database.