CQI in CDI

Roderick M. Napulan
Division Chief, Research and Performance Management Division,
DOH Health Facility Development Bureau
Adviser, Philippine Association of Health Records and
Information Officers
Professorial Lecturer, West Visayas State University College of
Medicine and University Medical Center
Associate Member, National Research Council of the Philippines
QUALITY ASSURANCE
Overview
RATIONALE From “quality control and

03
assessment” to the definition of

01
agreed and valid standards,
Quality improvement in health systematic and reliable
system needs to be organized measurement of performance,
systematically and appropriately implementing action for change,
linked to accreditation and safety repeated measurement and
continuous improvement in a
cycle

02 04
Uphold quality literacy at all Success of quality initiatives lies
levels and promote just culture in producing people and
and policy environment organization work
 QUALITY ASSURANCE QUALITY CONTROL

Assurance: The act of giving Control: An evaluation to indicate

confidence, the state of being certain needed corrective responses; the
or the act of making certain. act of guiding a process in which
variability is attributable to a
Quality Assurance: The planned and
constant system of chance causes.
systematic activities implemented in
a quality system so that quality Quality Control: The observation
requirements for a product or service techniques and activities used to
will be fulfilled. fulfill requirements for quality.

Source: http://asq.org/index.aspx
 QUALITY ASSURANCE A part of quality management focused
01 “ISO 9000 STANDARDS, on providing confidence that quality
CLAUSE 3.2.11” requirements will be fulfilled

QUALITY CONTROL
A part of quality management focused
02 “ISO 9000 STANDARDS,
on fulfilling quality requirements
CLAUSE 3.2.10”

SOURCE: ISO 9000:2005(en):Quality management systems

 Poor results can:

Affect patient safety and welfare

due to:

■ Inappropriate action or
inaction

WHY QUALITY ■ Incorrect treatment resulted

ASSURANCE IS from poor documentation
IMPORTANT?
 PURPOSE OF QUALITY ASSURANCE

To meet the rising expectations Bring to notice of hospital

1 of consumers of quality of administrations, about the
4 deficiencies and in correcting
services
the causative factors.
Help patients by improving
2 quality of care. Help exercise a regulatory
5 function.
Assess competence of medical Restricting undesirable
staff, serve as an impetus to 6 procedures.
3 keep up to date and prevent
future mistakes. 7 Eliminating medical errors.
 METHODS OF QUALITY ASSURANCE

A retrospective quality assurance A concurrent quality assurance evaluates

measures actual documented patient care while it is in progress.
outcomes against desirable and Documentation of the caliber of care
valued outcomes. being delivered is obtained through
Data for documentation of actual review of the patient’s chart, interview,
outcomes are obtained from the observations, and examination of the
medical records of a specific patient patient.
population after the patients have The advantage of concurrent review is
been discharged. that it can provide opportunities for
improvement of patient care while it is
in progress.
COMPONENTS OF QUALITY ASSURANCE

Strategic or organizational level (dealing with the quality policy,

1 objectives and management and usually produced as the Quality
Manual);

Tactical or functional level (dealing with general practices such as

2
training, facilities, etc); and

Operational level (dealing with the Standard Operating Procedures

3
(SOP’s) worksheets and other aspects of day to day operations).
 MODELS OF QUALITY ASSURANCE
DONABEDIAN MODELS/METHODOLOGY
STRUCTURE ELEMENT
Physical, financial and
1
organizational resources
provided for healthcare
PROCESS ELEMENT
Activities of a health system
2
or healthcare personnel in
OUTCOME ELEMENT
the provision of care
A change in the patient’s
3 current or future health that
results from medical
interventions
 MODELS OF QUALITY ASSURANCE

ANA MODELS/
METHODOLOGY
 MODELS OF QUALITY ASSURANCE

PDCA MODELS/
METHODOLOGY
 APPROACHES OF QUALITY ASSURANCE

1. GENERAL APPROACH:
It involves a large governing or official bodies’ evaluation of a person or
agency to meet established criteria or standards at a given time.

● Credentialing
● Licensure
● Accreditation
● Certification
1. Specific Approach:
 APPROACHES OF QUALITY ASSURANCE

1. GENERAL APPROACH:
It involves a large governing or official bodies’ evaluation of a person or
agency to meet established criteria or standards at a given time.

Process by which the eligibility of an entity for

● Credentialing
a particular job or task is established by
● Licensure determining if the entity has the specified
● Accreditation qualifications and fulfills the defined
● Certification requirement

1. Specific Approach:
 APPROACHES OF QUALITY ASSURANCE

1. GENERAL APPROACH:
It involves a large governing or official bodies’ evaluation of a person or
agency to meet established criteria or standards at a given time.

● Credentialing Individual licensure is a contract between the

profession and the state, in which the profession
● Licensure is granted control over entry into and exit from
● Accreditation the profession and over quality of professional
● Certification practice

1. Specific Approach:
 APPROACHES OF QUALITY ASSURANCE

1. GENERAL APPROACH:
It involves a large governing or official bodies’ evaluation of a person or
agency to meet established criteria or standards at a given time.

● Credentialing
Is the process of formally obtaining credibility
● Licensure from an authorized body, such as the
● Accreditation International Organization for Standardization
● Certification (ISO), Joint Commission International (JCI), etc.

1. Specific Approach:
 APPROACHES OF QUALITY ASSURANCE

1. GENERAL APPROACH:
It involves a large governing or official bodies’ evaluation of a person or
agency to meet established criteria or standards at a given time.

● Credentialing
● Licensure Usually a voluntary process within the profession.
A person’s education, experience and performance
● Accreditation on examination are use to determine the person’s
● Certification qualification for functioning in an identified
specialty area.
1. Specific Approach:
 APPROACHES OF QUALITY ASSURANCE

2. Specific Approach:
❏ Peer Review
❏ Standard as a device for Quality Assurance
❏ Audit as a tool for Quality Assurance
❏ Utilization Review
❏ Evaluation Study
❏ Client Satisfaction Survey
❏ Incident Review
❏ Quality Control
❏ Quality Rewards
 1 OUTPATIENT DEPARTMENT

EMERGENCY MEDICAL
2 SERVICES

3 IN-PATIENT SERVICES

AREAS OF QUALITY 4 SPECIALTY SERVICES

ASSURANCE

5 TRAINING
TYPES OF QUALITY ASSURANCE
 FACTORS AFFECTING QUALITY ASSURANCE

1. Lack of Resources
2. Personnel Problems
3. Improper Maintenance
4. Unreasonable patients and attendants
5. Absence of well informed population
6. Absence of Accreditation Law
7. Lack of Incident Report
8. Lack of Management Information System
9. Absence of Patients Satisfaction Survey
10. Lack of medical Records
CONTINUOUS
QUALITY IMPROVEMENT
Roderick M. Napulan
Division Chief, Research and Performance Management Division,
DOH Health Facility Development Bureau
Adviser, Philippine Association of Health Records and
Information Officers
Professorial Lecturer, West Visayas State University College of
Medicine and University Medical Center
Associate Member, National Research Council of the Philippines
CQI PROJECT

Additional work …?
OBJECTIVES

Understand the role and benefit of Continuous Quality

1 Improvement (CQI)

Use PDCA tools in CQI Project to improve the quality of

2 patient care and services

3 Apply the process to develop a CQI Project

WHAT IS CQI? CONTINUOUS QUALITY
IMPROVEMENT
● A process through which the level of
quality is defined, pursued, achieved
and continuously improved through
the establishment of formal
mechanism/system and structure
within the organization.
● Strategic approach to provide the best
health care possible for all
● Preventive strategy that uses constant
innovation to improve work processes
and systems by reducing
time-consuming and low-value
activities.
QUALITY IMPROVEMENT
Refers to an organizational strategy
that formally involves the analysis of QUALITY OF CARE
process and outcomes data and the
application of systematic efforts to Refers to the degree to which health
improve performance services for individuals and
populations increase the likelihood
QUALITY MANAGEMENT SYSTEM of desired health outcomes and are
consistent with current
Refers to a set of interrelated or professional knowledge.
interacting elements of an organization
relating to the establishment of quality
process which includes policies,
objectives, planning, assurance and
improvement.
CQI POLICY
AO 2020-0034
General guidelines
A. CQI shall be planned and identified as a priority of all health facilities along with the
identified priorities of Universal Health Care of access, coverage and financial
protection.
B. All health facilities shall implement a CQI Program at all levels of care
C. CQI shall be sustained by following a number of steps and principles applied namely
transparency, people centeredness, measurement, generation of information and
investing on the workforce, all underpinned by leadership and supportive culture.
D. A Quality Improvement (QI) TEam/Unit shall be organized and shall serve as an advisor
body to the head of the health facility.
SPECIFIC guidelines
A. CQI Program Structure
1. The health facility shall have a unit that will oversee the implementation of the planned activities
of the program. Pending approval of the Department of Budget and Management (DBM) on the
Proposed Staffing Standard, the unit shall be headed by a healthcare worker trained in CQI.
Support staff with CQI experience shall be provided by the health facility. The CQI committee as
mandated by Department Circular No. 2018-0131 or the Revised Licensing Assessment Tools for
Hospitals, and Administrative Order No. 2012-0012 or the Rules and Regulation Governing the
new Classification of Hospitals and other Health facilities in the Philippines, shall work with the
unit to ensure facility-wide implementation. In a local government setting, a unit shall be
designated to oversee the activities in all the health facilities under its jurisdiction.
SPECIFIC guidelines
A. CQI Program Structure
2. Continuous Quality Improvement shall be institutionalized in the policies,
systems and processes of the health facility or in the LGU unit governing the
health care facilities.
3. Adequate and appropriate qualified staff shall be maintained. Continuous
capacity building programs shall be in place in line with the development
plan of the health facility.
4. Training to capacitate all staff on CQI shall be continuously scheduled in
coordination with the Professional Education, Training and Research Unit
(PETRU) or its equivalent.
SPECIFIC guidelines
A. CQI Program Structure
5. Conduct Annual Operational Planning shall be reflected in their respective
Work and Financial Plan (WFP) or as the case maybe. Funds shall be allocated
for CQI activities. The provision and maintenance of quality healthcare
services need not be expensive and/or dependent on the capability of the
facility.
6. Implementation of CQI shall be harmonized with ongoing initiatives to
pursue Quality Management System. However, certification or accreditation
from third parties (e.g. PGS, ISO and other international accreditation bodies)
is optional for facilities that do not have existing requirement for such.
SPECIFIC guidelines
B. CQI Process
1. The systems and processes ofthe health facilities shall adhere to the elements of Quality
(ANNEX B).
2. Health facilities shall:
A. Implement a computerized integrated health information and management system;
B. Benchmark with the standards and policies published by the DOH including the
programs such as, but not limited to, Patient Safety, Infection Control, People
Centeredness and the 12 Manuals on the Standard of Operations issued by the Health
Facility Development Bureau.
3. The program shall document CQI activities for future best practice reference, and report
outputs and outcomes as tool for monitoring and evaluation.
 1 PEOPLE CENTEREDNESS

2 EFFECTIVENESS

3 SAFETY

4 EFFICIENCY

5 EQUITY

ELEMENTS OF CQI 6 ACCESS

PROGRAM
7 APPROPRIATENESS
 1 PEOPLE CENTEREDNESS

2 EFFECTIVENESS

3 SAFETY

4 EFFICIENCY

5 EQUITY

ELEMENTS OF CQI 6 ACCESS

PROGRAM
7 APPROPRIATENESS
PEOPLE-
CENTEREDNESS
“An approach to care that focuses
on what is valued by the client,
individuals, families, and
communities, and sees them as
participants as well as beneficiaries
of trusted health systems that
respond to their needs and
preferences in holistic and humane
ways” -(WHO, 2016) -
 1 PEOPLE CENTEREDNESS

2 EFFECTIVENESS

3 SAFETY

4 EFFICIENCY

5 EQUITY

ELEMENTS OF CQI 6 ACCESS

PROGRAM
7 APPROPRIATENESS
EFFECTIVENESS
Delivering health care and
products that improve health
outcomes for individuals and
communities, based on need as
supported by evidence-based
knowledge.
 1 PEOPLE CENTEREDNESS

2 EFFECTIVENESS

3 SAFETY

4 EFFICIENCY

5 EQUITY

ELEMENTS OF CQI 6 ACCESS

PROGRAM
7 APPROPRIATENESS
SAFETY
Delivering health care and product
which minimize risks and harm to
service and medical product users;
health care and products that ensure
that the patients and staff do not
suffer undue harm from the
treatment itself and from the manner
it was given.
 1 PEOPLE CENTEREDNESS

2 EFFECTIVENESS

3 SAFETY

4 EFFICIENCY

5 EQUITY

ELEMENTS OF CQI 6 ACCESS

PROGRAM
7 APPROPRIATENESS
EFFICIENCY
Delivering health care and
products in a manner which
maximizes resource use and avoid
waste (technical efficiency);
resources are used appropriately
to ensure optimum benefits for
patients and the population
(allocative efficiency).
 1 PEOPLE CENTEREDNESS

2 EFFECTIVENESS

3 SAFETY

4 EFFICIENCY

5 EQUITY

ELEMENTS OF CQI 6 ACCESS

PROGRAM
7 APPROPRIATENESS
EQUITY
Implies considerations of fairness
so that in some circumstances,
individuals will receive more care
than others to reflect differences
in their ability to benefit or in their
particular needs.

Regardless of socio-economic status,

religion, gender, race, ethnicity, political
inclination, or geographical location.
 1 PEOPLE CENTEREDNESS

2 EFFECTIVENESS

3 SAFETY

4 EFFICIENCY

5 EQUITY

ELEMENTS OF CQI 6 ACCESS

PROGRAM
7 APPROPRIATENESS
ACCESS
Ability of the people to obtain
health care and products that are
timely, geographically and
financially reasonable,
socio-culturally sensitive and
provided in a setting where skills
and resources are appropriate to
medical need.
 1 PEOPLE CENTEREDNESS

2 EFFECTIVENESS

3 SAFETY

4 EFFICIENCY

5 EQUITY

ELEMENTS OF CQI 6 ACCESS

PROGRAM
7 APPROPRIATENESS
APPROPRIATENESS
Defined as that care is effective (based
on valid evidence); efficient (cost-
effectiveness); and consistent with the
ethical principles and preferences of
the relevant individual, community or
society.
Appropriateness contains a judgment
regarding care at different decision
levels (such as health care delivery, and
research and development) that
summarizes clinical, public health,
economic, social, ethical and legal
considerations.
 CQI PROCESS

PDCA MODELS/
METHODOLOGY
BENEFITS OF PDSA CYCLE

❏ Scientific approach to
improvement
❏ Rapid identification of effective
solutions
❏ Small scale testing to reduce
waste in resources
❏ Structured and organized
improvement process
❏ Systematic documentation to
facilitate learning and
dissemination of ideas
PDCA MODELS/METHODOLOGY - PLAN
Step 1: Organize the Team
Step 2: Problem Identification (brainstorming)
Step 3: Prioritize the Problem (Use of Prioritization Matrix Tool)
Step 4: Select the highest score
Step 5: Describe the problem
Step 6: Clarify the problem
● Check current process
● Do RCA/5whys
Step 7: Formulate solution(s) (Use Brainstorming)
Step 8: Best Practice/ Benchmark (review literatures)
Step 9: Establish Goals
STEP 1 STEP 2
ORGANIZE THE TEAM PROBLEM IDENTIFICATION

❏ Identify & involve stakeholders (e.g. ❏ Find a process that needs

improvement
physicians, nurses, admin…etc.)
❏ Use Brainstorming
❏ Cover all related departments to the
improvement initiative

❏ Select team members who best do or

know the process to be improved
STEP 2
PROBLEM IDENTIFICATION

Other methods/sources of information:

❏ Complaints
❏ Incident reports
❏ Environment of Care (EOC) round
findings
❏ Surveys
❏ Research Findings
❏ Findings during Executive Rounds
STEP 3
PRIORITIZE THE PROBLEM

Utilize the Prioritization Matrix Tool

Feasibility
High Risk/ Problem Prone/ High Important Regulatory Customer Staff/Doctor High Cost
of Data
Opportunity Safety Poor Outcome Volume to Mission Requirement Satisfaction Satisfaction from Failure Score
Collection
(x10) (x9) (x8) (x7) (x7) (x6) (x6) (x4)
(x5)
 Criteria Weight Score

High Risk Issue ( Safety to staff and patient) 10 1 – Low Risk 3 – Medium Risk 5 – High Risk

Problem Prone or Poor Outcome 9 1 – Low 3 – Medium 5 – High

High Volume Issue 8 1 – Low Volume 3 – Medium Volume 5 – High Volume

Importance to Mission & Strategic

7 1 – Low 3 – Moderately related 5 – Directly related
Performance Priorities

1 – Not/Barely significant 3 – Moderately significant

Regulatory Requirement 7
5 – Highly significant

Customer Satisfaction 6 1 – Low 3 – Moderate 5 – High

Staff/Doctor Satisfaction 6 1 – Low 3 – Moderate 5 – High

1 – Not/ Hardly Feasible 3 – Moderately Feasible

Feasibility of Data collection 5
5 – Highly Feasible

High cost from Failure 4 1 – Low 3 – Medium 5 – High

EXAMPLE

Problem Feasibility of High Cost

High Risk/ High Important to Customer Staff/Doctor
Prone/ Poor Data from
Opportunity Safety Volume Mission Score Satisfaction Satisfaction
Outcome Collection Failure
(x10) (x8) (x7) (x6) (x6)
(x9) (x5) (x4)

Problem A 1 x 10 5x9 1x8 3x7 3x7 1x6 3x6 5x5 1x4 158

Problem B 3 x 10 1x9 3x8 1x7 5x7 5x6 3x6 3x5 1x4 172

Problem C 5 x 10 3x9 1x 8 5x7 3x7 1x6 1x6 1x5 1x4 162

Problem D 3 x 10 5x9 3x 8 1x7 1x7 3x6 3x6 5x5 1x4 178

Problem E 1 x 10 1x9 1x 8 3x7 1x7 5x6 1x6 1x5 5x4 116

STEP 4 STEP 5
DESCRIBE AND QUANTIFY THE
SELECT THE HIGHEST SCORE PROBLEM

❏ After the prioritization of the problem ❏ Provide a brief and concise

using the prioritization matrix tool statement about the problem
identifies
❏ Choose the top three problems with
the highest score being the priority
projects
STEP 6
CLARIFY THE PROBLEM

❏ Check the current process:

❏ Check the policy
❏ USe flowchart to describe
workflow (optional)
STEP 6
CLARIFY THE PROBLEM

Do Root Cause Analysis (RCA)

❏ Brainstorming
❏ Fishbone Method
❏ 5whys strategy
STEP 7 STEP 8
FORMULATE SOLUTIONS BEST PRACTICE/BENCHMARK

❏ Based on RCA
❏ Look for related literatures
❏ Brainstorming (Evidence-based)
❏ Solutions/strategies from other ❏ Have a benchmark for best practice
hospital
STEP 9
ESTABLISH THE GOALS

Using S.M.A.R.T Criteria to Define a Clear Goal

S = Specific

M= Measurable

A = Achievable

R = Reasonable

T = Time-Bound
 🗐 Prepared by: Roderick M Napulan

HIMD PERFORMANCE MEASURES

Measures Numerator Denominator Frequency Benchmark

Number of patient
Total number of 100%
Coverage Rate records reviewed in a Monthly
discharges in a period Compliance
period

Discharge Summary Number of complete Number of patient 85%

Monthly
Completion Rates discharge summary records reviewed Compliance

Hospital Inpatient Number of complete

Number of inpatient 85% Completion
Record Completion inpatient records without Monthly
records reviewed Rates
Rates any deficiencies

Number of complete OPD Number of OPD

OPD Record 85%
records without any records reviewed Monthly
Completion Rates Compliance
deficiencies

Number of complete ER
Number of ER records 85%
ER Completion Rates records without any Monthly
reviewed Compliance
deficiencies
 🗐 Prepared by: Roderick M Napulan

HIMD PERFORMANCE MEASURES

Measures Numerator Denominator Frequency Benchmark

Number of patient Number of patient 95%

Closed Medical Record
records (OPD, ER and IP) records reviewed Monthly compliance to
Review Results
without any deficiencies (OPD, ER and IP) all standards

Number of patient
Number of patient 95%
Open Medical Record records in wards
records in wards Monthly compliance to
Review Results reviewed without
reviewed all standards
deficiencies

Number of patient Number of patient

Physician Query records complied by records returned to 85% response
Monthly
Response Rates physicians within the Physicians for rate
prescribed timeline Compliance
PDCA MODELS/METHODOLOGY - DO
❏ Establish the Action Plan
● Action Plan define:
○ Key steps to:
■ Implement the solution
■ Educate/Notify
■ Monitor Compliance
○ Who will do each step
○ When the step should be completed
PDCA MODELS/METHODOLOGY - DO
❏ Establish the Action Plan
● Action Plan define:
○ Key steps to:
■ Implement the solution
■ Educate/Notify
■ Monitor Compliance
○ Who will do each step
○ When the step should be completed
 MODELS OF QUALITY ASSURANCE

PDCA MODELS/METHODOLOGY - DO

EXAMPLE
PDCA MODELS/METHODOLOGY - CHECK

1. Create monitoring tool

2. Create measuring tool
3. Collect Data
4. Check Data and Analyze
5. Compare:
● Benchmark/Best Practice
● Trends
 MEASUREMENT IN PDSA CYCLE

1. PROCESS MEASURES

❏ Used to understand implementation of the change strategy.

❏ Help assess fidelity when testing a change strategy.
❏ Support scaling up.

2. OUTCOME MEASURES

❏ Used to determine if there is a change as a result of the change strategy tested.

3. BALANCING MEASURES

❏ Used to identify unintended consequences of the change strategy.

 MODELS OF QUALITY ASSURANCE

PDCA MODELS/METHODOLOGY - ACT

❏ Act?
1. Standardize: Policies and Procedures
2. Sustained? Check
A. By continuously monitoring (use of the Measure Profile and Graph)
B. STOP: 4 Consecutive Months achieve above target
❏ Adjust?
1. Improve: Go back to the PLAN and Repeat the Process
❏ Dissemination – keep the stakeholders updated of the results
Case Scenario

You are assigned by the Medical Director/Medical Center Chief/Hospital Head to study on how to
improve the health records documentation in your hospital and determine the revenue impact of
the initiative.

The hospital has 20% incomplete records upon discharge and RTH of 25%. The hospital don’t have
any policies on the health information management. Majority of the medical staff are newly hired.
Health record forms were updated 3 years ago.

Task:

Apply principles and process of the CQI to improve the health records completion and
documentation.
Project Name: Documentation Improvement in OB Records
Implementation Range: November 2021 to June 2022

Developer: HIM Head/OB Resident Chief Approved by: Hospital Director

Reference Number: Date:

PLAN
Name
1. ☐ Organize the team.
Approver of Decisions: Hospital Chief

Resource persons/ experts: Quality Assurance Department; DOH; Philhealth

Members of the Team HIM Head
OB Chief Resident
Nurse Supervisor
Forms Committee Rep
OB Doctor
Billing and Claims Rep
Analysis Clerk/Compliance Officer
2. ☐ Problem Identification (use brainstorming)
Completion rate of OB records is high
INCOMPREHENSIVE HISTORY
Obsolete health records forms
Missing Partograph
No existing/absence policies on HIM
Inconsistent demographic profile (misspelled and wrong info)
RTH is high
Telephone orders not signed
Illegible handwriting
Incomplete diagnosis
Difficulty in doctors sched to comply/complete the charts in him
Difficulty in doctors sched to comply/complete the charts in him Main problems
Incomplete CF4
High transferred critical admissions
Discrepancy of lab results and Dx Incomplete health records
Incomplete chart
No signature of doctors
Laate results of diagnostics and laboratory
Poor documentation
Forms not signed
Untrained staff Lack of training
Late submission of charts
Empty surgical technique
Machine needed not functional Lack of policy and procedures
Missing pages
No nurses notes
Underpaid staff Lack of equipment maintenance
wrong details of patients
incomplete NB record
1. ☐ Prioritize the problem (use prioritization matrix – Annex A)

Priority Problem
A.
Incomplete health records

B.
Poor documentation

C. Lack of policy and procedures

2. ☐ Select the top 3 highest score

Incomplete health records

Prioritization Matrix

Opportunity High High Problem Importa Customer Staff/Doc High Feasibili Regulatory Score
Risk/ Volume Prone/ nt to Satisfactio tor Cost ty of Requireme
Safety Poor Mission n Satisfacti from Data nt
Outcom on Failure Collectio
e n

weight 10 8 9 7 6 6 4 5 7

0
3. ☐ Describe & quantify the Problem

The hospital has 20% incomplete records upon patients’ discharged.

4. Clarify the problem

☐ Check the current process

Process of analysis of health records and feedback is not sustained.

There is no training for doctors on records completion

☐ Do RCA/5whys (Use Root cause analysis form – Annex B)

Root cause analysis

PROBLEM:

High incomplete health records

Manpower Material

- Proximate cause 1: - Proximate cause 1:

+ why? + why?

+ why? + why?

Method / process Machinery

- Proximate cause 1: - Proximate cause 1:

+ why? + why?

+ why?

Environment

- Proximate cause 1:

+ why?

+ why?

+ why?
Root cause analysis
Machinery Manpower Method

No feedback
Lack of computers Quarantined staff Lack of doctors and
Lacks concurrent mechanism
nurses with
overwhelming checking
Fear of COVID19
patients / Exhausted
infections Assessment is
Poor printing staff lack of
maintenance communication/ incomplete
Poor time endorsement
management Non functioning PHRC

lack of Lack of training

Lack of trainers initiatives due
Problem:
awareness of duties
and responsibilities to lack of
incentives
High incomplete
Poor management Lack of Budget
support health records

Poor internet Forms printing

connection quality not good

Lack of spaces for Procurement

Redundant forms
doctors, nurses and problem
other allied staff for
the completion of
Forms not always
records
available

Environment Material
5. ☐ Formulate solution(s) (Use Brainstorming)
No Solution
1 Reactivation of PHRC

2 Review and updating of Forms

3 Active and Close records review and feedbacking

4 Provisional process and policy

5 Monitoring and feedbacking

6 Conduct Trainings and Orientations

Request for computers and high speed printers
Maintenance of computers
Award for Best Employee on Clinical Documentation and Records Completion
Penalty for delayed and incomplete patient health records
6. ☐ Refer Best Practice/ Benchmark (review literatures)

No Literature/Best practice
Active records review
Incentivations
Review of clinical practice guidelines
7. ☐ Establish Goals
In six months, the following shall be achieved:

Increase revenue by 5%
Decrease RTH to zero
Decrease RTH to 5%
Decrease delinquent charts by 10%
Decrease incomplete chart from 20% to 10%
Increase completion rate from 80% to 90%
Decrease RTH from 25% to 10%
100% complete health records upon discharged of patient
BY : baseline x (100% + %)
Example: 80% x (100%+5%) = 80% x 105% =84%
1. ☐ Establish the action plan. - Include: implementation, education/notification
and compliance monitoring plan

2. ☐ Implement the action plan.

Action Plan
When Estimated Budget
No What (Tasks) Who Requirements
Start End

1 Reactivation of PHRC

Coordinate with MCC to activate

PHRC

Drafting and approval of hospital

order

Meeting with PHRC

2 Review and updating of Forms

Conduct baseline survey/Interview

with OB doctors for the forms that
need to update
Review the forms with stakeholders
and PHRC
Action Plan When Estimated Budget
No What (Tasks) Who
Start End Requirements

3 Active and Close records review and

feedbacking
Standards orientation and devt of
checklist with analysis clerk
Random sampling of records

Monitoring

4 Provisional process and policy

Meeting and consultations

Drafting and approval

5 Monitoring and feedbacking

Monitoring sheets

Graphs
1. ☐ Create monitoring tool

2. ☐ Create Measuring tool (use the measure profile – Annex C)

Measure Profile
MEASURE ITEMS

Measure Name: Completion Rate of OB Inpatient Health Records

Data collection done by: HIMD
Method of Data Collection (Retrospective or Concurrent): Retrospective
Type of Measurement (Process Measure or Outcome Measure): Outcome
Rationale: To ensure compliance with DOH and PHilhealth standards and improvement of health records management
Raw Data Collected: Number of discharges of inpatients reviewed; records not complete based on the
review
Excluded population: outpatients; non-OB
Data Collection Source of Data: HIMD database
Method
Sampling methods: Random
Sample Size:
https://manual.jointcommission.org/releases/TJC2013B/SamplingChapterTJC.html#Sampling
Data to be computed: Percentage of completion
Measure Unit: Per 100 record or %
Data aggregation Schedule: Monthly
Anticipated reporting time: 3 working days after the end of the month; Every 10th of the month
Data Aggregation and
Analysis Plan Formula:
Number of complete inpatient records without any
Measure Profile

Frequency Assessment:
Daily
Target/Goal: 90%

Data Aggregation and Analysis Plan Explanation: Higher the completion and above 90% will be considered acceptable

Benchmark value (if available, and precise source): 85% (assuming)

Department or committee responsible:

HIMD
Project Team

Departments, services, committees, or individuals receiving reports/report cycle :

PHRC
ManComm
EXECOM

Validation data:

References:
3. ☐ Analyze and Evaluate the results
Month 1 Month 2 Month 3 Month 4 Goal

Numerator: 75 80 90 95

Number of complete
inpatient records
without any
deficiencies
Denominator: 100 100 100 100

Number of inpatient
records reviewed

Compliance Rate: 75% 80% 90% 95% 90%

Analysis: Decrease from Increase from Increase Continuous

the baseline of month 1; Same compared last increase on the
80% and below as the baseline month; Higher performance;
4. ☐ Compare the result with the goal
Achieved desired results?
☐ Yes – go to ACT
☐ No – return to PLAN to adjust.

Yes. Achieved after 4 months;

☐ Sustained?
☐ Yes – go to Standardize
☐ No – return to PLAN to adjust.

☐ Standardize: Policies and Procedures

Revised policies and recommend for

adoption for hospital wide implementation
Roderick M. Napulan
Division Chief, Research and Performance Management
Division, DOH Health Facility Development Bureau
Adviser, Philippine Association of Health Records
and Information Officers
Professorial Lecturer, West Visayas State University
College of Medicine and University Medical Center
Associate Member, National Research Council of the
Philippines