Every Day is Time Out Day

On June 17, 2009 the AORN (Association of periOperative Registered Nurses) honored National Time Out Day.

“National Time Out Day reminds every member of the surgical team how critical it is to take time out for patient safety. Confirm correct patient, correct procedure, and correct surgical site before every invasive procedure.”

With ComplyMD, Every Day is Time Out Day. Our perioperative surgical documentation tool allows physicians and nurses to document in real-time the exact moment of the Surgical Time Out. So, there’s no question if it took place; there’s only evidence that the entire Surgical Team was in agreement at that time of the patient, procedure and site.

Time Outs are critically important in the Operating Suite. “Wrong-site surgery and other preventable mistakes still occur too frequently in US operating rooms.” These mistakes are often attributed to the Surgical Team not taking time to stop and assess the patient’s information and situation, but hurriedly rushing into each case and packing into a day as many surgeries as possible. Care is not always taken to assess the current situation with the current patient and make sure everyone is agreement on information regarding the patient, procedure and site before one incision is made.

This is why in 2004, “Joint Commission released the Universal Protocol urging that a ‘time out’ precede every surgical procedure to verify the correct patient information prior to incision. In support of the Universal Protocol, AORN began sponsoring National Time Out Day to raise awareness about the importance of requiring the entire surgical team—including physicians, nurses, and surgical technologists—to pause before all invasive procedures to communicate as a group and confirm key information about the patient and procedure to help prevent errors from occurring.”

Notice that phrase “key information about the patient” in the sentence above? Patient ID, procedure and site are important to ‘check’ before all procedures. But what about other “key information”? For example, “patient is allergic to penicillin”, “patient with an old MI”, “patient has COPD”, “patient is deaf”, etc. All of these (I would hope) qualify as “key information”. And most all of these would impact the way the Surgical Team cares for the patient, right? ComplyMD offers the luxury of having all of that information right in front of the Surgical Team at the Time Out on one single screen. So, nurses and docs don’t have to spend time flipping through the patient chart to find all the info, it is all captured on one easy-to-read screen (or printout). The ComplyMD Time Out is not only effective but efficient.

Consistent use of ComplyMD’s Surgical Time Out entry field satisfies Joint Commission’s requirement for the Time Out to be documented just before every invasive procedure.

“This year, AORN collaborated with American Nurses Association, the American Association for Accreditation of Ambulatory Surgical Facilities, the Council on Surgical & Perioperative Safety, and The Joint Commission to create a poster to remind professionals, health care providers, and administrators that ‘Every Day is Time Out Day.’”

They also had a National Time Out Day Video Content. To view some of the vidoes that demonstrate the Surgical Time Out procedure, click here and scroll down.

Efficiency, Comprehensiveness and Cost-effectiveness when comparing Dictation and Electronic Templates for Operative Reports

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1560865

Here’s a great article comparing dictation to electronic templates. The results are pretty amazing. Looking at the time, efficiency, comprehensiveness and cost-effectiveness of the two could turn some heads towards electronic templates.

The study was done in Wishard Memorial Hospital’s (Indianapolis, IN) OB-GYN Department. During the four four-week study blocks, they performed 478 procedures on 440 patients corresponding to 5 selected study procedures. They evaluated the effects of templates on timeliness of completion, comprehensiveness and costs, and effort required vs. standard dictation. 

Most in the healthcare industry would agree that: “Dictated reports are frequently incomplete or delayed.” However, it could take some results like the ones in this article to show that: “Electronic note templates could potentially improve this process.”

“Templates resulted in dramatically faster times to the presence of a verified operative report in the medical record compared to dictation services (mean 28 v. 22,440 minutes). Templates increased overall compliance with national standards for operative note documentation and avoided transcription costs. Documentation with templates took slightly more time than dictation (mean 6.77 v. 5.96 minutes; P=0.036), not including the additional time necessary to subsequently verify dictated reports. We conclude that electronic note templates can improve the timeliness and comprehensiveness and operative documentation while decreasing transcription costs and requiring minimal additional effort on the part of the surgeons.”

Accurate Charge Capture: Help Physicians Acquire Appropriate Documentation

“With profit margins squeezed so tightly in the healthcare industry, it’s hard not to think that any loss of revenue would not affect the bottom line. Accurate charge capture and claims denial management processes mean not only improving cash flow, but also protecting revenue that the provider is entitled to—and that all adds up to a healthier bottom line.”

“Improving Cash Flow with Better Charge Capture & Denial Management” MedAssets & HFMA. October 2005

Yes. We are all aware of tightly squeezed profit margins. But, do we know how to improve those profit margins? Accurate charge capture and claims denial management are two such areas that could help improve a healthcare organization’s bottom line. Let’s look at inaccurate charge capture vs. accurate charge capture. Inaccurate charge capture can be caused for several reasons, such as undercoding (loss of revenue), overcoding (risk of fraud), lack of knowledge in accurate documentation, lack of tools to capture accurate charges, etc. The list goes on and on.

Do You Equip Your Physicians with the Proper Tools?

“Hospitals across the country lose multiple millions of dollars every year due to mismanagement of the billing process. No matter the size of the organization, billing inconsistencies affect all healthcare facilities to some degree—even those that are on top of the problem. On average, providers lose 5 percent of gross revenues, and that can translate into millions of dollars for a single organization.”

“Improving Cash Flow with Better Charge Capture & Denial Management” MedAssets & HFMA. October 2005

As we all know, profit margins are tightly squeezed in the healthcare industry. The billing process has a huge impact on those profit margins. What do facilities bill for? Patient encounters. How do they know what to bill for? Through physician documentation. How will these patient encounters be properly documented? There… you’re stumped. It’s not through dictation after the fact, and it’s not on their 3×5 index card they carry around in their pockets.