September 2017

Transcription Trends: Tips for HDS Performance Measurement
By Patricia King
For The Record
Vol. 29 No. 9 P. 10

Despite having undergone many changes and technological advancements over the years, the profession of health care documentation is alive and well. While many health care facilities have outsourced their transcription to both large and small medical transcription service organizations (MTSOs), there are a surprising number of health care organizations that have maintained their own workforce. These institutions and MTSOs alike use various methods and metrics to measure the performance of their health care documentation specialist (HDS) and quality assessment (QA) workforces.

In the face of heightened federal regulations, incentives, and penalties, quality medical records are more important than ever. Therefore, measuring and managing the performance of the HDS workforce is paramount.

New Kids on the Block
In addition to the more traditional assignments associated with documentation, a new role has emerged: clinician-created documentation integrity (CCDI) auditor. Because many front-end speech recognition platforms do not retain voice files, CCDI auditing is conducted without voice recordings. CCDI auditors are upper-level HDSs whose skills are well suited to this complex task.

Documents eligible for this type of review include both those typed by clinicians or their representatives directly into the EHR and those created with the use of front-end speech recognition. A growing number of organizations are pioneering this new method of measuring and maintaining quality medical records that supports patient safety and care as well as coding, billing, reimbursement, and medicolegal issues.

Measuring Up
Performance measurement of traditional HDS roles has long been based on simple metrics. Whether evaluating an HDS whose role is solely that of traditional transcription, an HDS who edits back-end speech-recognized draft text, or an HDS whose position combines those skill sets, the elements measured are the same: quality and productivity. (Time management may also be considered.)

Soft skills must also factor in performance evaluations. Most importantly, it is essential to remember that each HDS is a unique human being with distinct aptitudes, capabilities, and behavioral traits.

Organizations must have a robust and comprehensive QA program with clearly defined policies and procedures and an adequate workforce to measure an appropriate and truly random sampling of transcribed and edited documents. The program should be easily understood and fully transparent to all staff members; likewise, it must be fairly delivered.

A successful QA program is based on a clear understanding of the organization's principles of quality, considers the factors affecting quality, various error categories and their definitions, and scoring method, and maintains rigorous sampling guidelines based on available resources. The Association for Healthcare Documentation Integrity (AHDI) recommends that QA auditing and scoring be used to further educate HDSs but not to tie scores to compensation.

As outlined in the Healthcare Documentation Quality Assessment and Management Best Practices Toolkit, AHDI recommends HDSs maintain a standard quality score of 98% or higher. In addition, AHDI emphasizes the need to eliminate critical errors that could potentially affect patient safety and care.

Similar to a traditional QA program, a CCDI initiative must feature a set of quality principles devoted to reducing critical errors that could affect patient safety and care. However, CCDI principles may vary slightly from those found in a traditional QA program due to direct interaction with the clinicians themselves.

Measurement Tools
Productivity has long been measured by the number of lines transcribed or edited per hour, although some facilities use the dictated minute as a metric. However, the number of lines transcribed or edited from a single dictated minute can vary greatly based on the dictating author. As a result, unless there is an extremely conscientious effort to evenly distribute various authors among the HDSs, the dictated minute method is a less accurate productivity measure than the transcribed or edited line method.

Depending on an organization's compensation method, time management may be evaluated when assessing HDS performance. When HDSs are paid for each line or minute they transcribe or edit, there is less need to measure time management. A facility that pays its HDS staff by the hour may be more inclined to establish a time management standard metric for its workforce. For example, take a 12.5% maximum time management metric. This translates to one hour of nontranscription or nonediting time per eight-hour workday, providing HDS staff one cumulative hour's time for administrative duties such as e-mail and timekeeping, terminology research, equipment procedures, and verification of information within the EHR. It may also include paid breaks.

In a CCDI program, auditors are evaluated using several factors, such as which error types are identified and the number of critical and noncritical errors identified. Organizations that have implemented these programs have begun to monitor quality and productivity and establish corresponding standards for staff. Some organizations are requiring staff to receive continuing education and/or earn registered health care documentation specialist or certified health care documentation specialist credentials.

It is recommended that all metrics be measured at regular intervals (weekly, biweekly, monthly, or quarterly) and tracked over time.

QA Auditors
Behind the scenes, QA auditors fill a vital role in the HDS workforce. Compared with other HDS staff, it can be challenging to measure their performance. Often considered to be the most highly skilled HDSs, QA staff are nevertheless human and subject to implicit bias as well as occasional errors.

It's important that QA auditors be evaluated to ensure their work (reviewing and providing feedback to the HDS staff) is accurate and consistent based on the organization's QA program. In organizations where more than one professional is performing QA, staff adherence to policies and procedures must be monitored in order to maintain fairness and equal educational opportunities to the HDS staff they serve.

To help achieve this goal, managers can audit several random documents and ask each of the QA staff to do the same independent of one another. Comparing the manager's "key" to the QA staff's audited documents may reveal areas of inconsistency and other potential issues, leading to opportunities for improvement. Findings should be shared with the staff, solutions sought, an action plan developed, and ongoing progress tracked. This process should take place at least quarterly and be conducted regularly. In small organizations, the manager may review the audited documents, listening to the voice file only when necessary. Errors should be documented, measured, and reviewed with QA staff in order to educate and evaluate performance.

Other Factors to Consider
While the various metrics pertinent to the traditional HDS role—transcribing and/or back-end speech editing—may seem straightforward, the metrics interact and, when combined with other qualities, skill sets, and traits, yield a variety of conclusions about performance.

For example, an HDS may produce at the minimum productivity standard, but his or her quality may be exceptional with few queries to the QA staff. Meanwhile, another HDS with the same productivity and quality standards may send a high percentage of documents to QA. To take the example a step further, an HDS may be highly productive but barely attain the minimum QA score or have difficulties with time management. Among this group, who's doing the best job?

Worth the Effort
The performance of QA staff can be challenging to measure. Managers may need to be creative in devising a method that works well in their specific environments. The role of CCDI auditors is still in its infancy, and metrics and other means of measuring the performance of this vital workforce are being developed.

Evaluating all of these metrics plus factoring in soft skills and behavioral traits is, at best, a complex and time-consuming effort for HDS managers. Nevertheless, this seemingly monumental task is a vital and necessary element to ensure patient safety and quality care. It's what inspires and galvanizes HDS managers as they measure the performance of their uniquely talented and essential staff.

— Patricia (Patt) King is manager of HIM transcription for Tucson Medical Center in Tucson, Arizona. King was involved in the creation of AHDI's The Compensation Best Practices Toolkit in 2015, was cochair of the Back-End Speech Recognition Implementation Best Practices Toolkit in 2016, and is the current chair of AHDI's Managers-Supervisors Alliance and cochair for the QA Best Practices Task Force (2017).