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Transcription Quality Best Practices: A Preview to the New Industry Standards
By Dale Kivi, MBA

As colleagues in an industry expected to be masters of the English language, we understand that a “burro” is a donkey, while a “burrow” is a hole in the ground. Every member of the medical transcription profession is expected to know the difference for such homonyms or any other grammatical nuance that could affect quality in clinical documentation.

Unfortunately, transcription quality assessments have been considered by some as the crossroads between “you can’t manage what you can’t measure” and “figures don’t lie but liars can figure,” especially when contrasting the quality compliance reports submitted by some outsourcing vendors against quality complaints from physicians for the same reporting period.

The Healthcare Documentation Quality Assessment and Management Best Practices document is now available to ensure assessment consistency. Formally released at this year’s Association of Healthcare Documentation Integrity (AHDI) annual meeting, the guide can be downloaded free of charge from the AHDI website (www.ahdionline.org) under the Resources tab, Best Practices and Standards Guidelines.

One of the more important contributions to this iteration of transcription quality best practices is the appendix on statistically valid sampling. Where departments or services previously relied on a random volume of reports, regardless of their length, per reporting period and/or a selection process based on the last digit of the document numbers to identify which documents to use for the assessment, the new guide offers the math and the sampling criteria for a statistically valid sample set.

When properly followed, the random selection guidelines of the new standards should ensure that no one can stack the deck with hand-selected reports in order to create the impression targeted accuracy levels are being met when any true random selection may prove otherwise.

To ensure sampling integrity in compliance with the new standards, the industry’s leading technology vendors have already integrated random report selection functions into their platforms to route user-defined percentages of reports into the editing pool, thus ensuring random as well as statistically valid sampling.

Developed over four years of committee work, the best-practice guide was a joint effort by industry experts representing the AHDI, the Clinical Documentation Industry Association (formerly the Medical Transcription Industry Association), and the AHIMA.

Like the two previous standards published by the collective associations on volume measurement and turnaround times, Healthcare Documentation Quality Assessment and Management Best Practices should notably improve the consistency in how quality as a clinical documentation workflow process variable is measured and reported by all in-house, outsourced, foreign, and domestic members of the medical transcription/clinical documentation industry.

To help achieve this goal, the best-practice recommendations include specific guidelines for assessment policies and procedures for concurrent review, retrospective review, flagged documents, feedback, and author assessments.

To coordinate the plan with other industry standards and best-practice recommendations supported by the AHIMA, the entire guide is presented in a Plan, Do, Check, Act format for continuous quality improvement, resulting in an easy-to-follow recipe.

In the end, the document provides a solid blueprint for the application of a leading-edge quality program that is compatible with paper-based medical records, hybrid EHR record systems, and fully implemented EHR systems.

Once applied, we can expect future assessment reports to more accurately reflect the quality of an in-house staff or outsourced service, regardless of how deeply one burrows into the details. After all, if pressed to evaluate their true performance quality, HIM directors certainly know the difference already.

— Dale Kivi, MBA, is director of business development for FutureNet Technologies Corporation.