Improving data quality
The medical record is the principal legal document recording the intended and actual care of a patient, together with the outcome.
Keeping good records is an essential factor in maintaining good clinical standards.
An E-health record holds the information formerly held in the patient’s notes, transferring the information onto an electronic clinical system in such a way that the information can be audited, extracted and shared.
The workload tool produces reports based on the clinically coded practice data and can be analysed to show individual clinicians. These reports enable the practice manager to check how data has been entered onto the clinical system.
Objectives
- To improve and maintain data quality within the practice
- To reach standard of data quality as required for the Summary Care Record (SCR).
- The practice team to agree a ‘formulary’ of codes
- To monitor and motivate the clinical team
- To ensure high quality of care for patients by accurate and consistent recording.
The Challenge for one practice
“Had a chat to patient” (8CB..) 2nd/3rd highest ranked READ code
- 180-190 entered in one month
- Starting position
| |
GP 1 |
GP 2 |
GP 3 |
GP 4 |
GP 5 |
GP 6 |
PR |
| Month 1 % of total |
23.96 |
2.27 |
3.63 |
0 |
1.01 |
2.29 |
7.47 |
The Solution
- Encouraged change using Workload Analysis to highlight problem
- Practice discussions of coding practice
- Individual user formularies to use when “had a chat” commonly used
- More data to be gathered to reinforce behaviour as appropriate
Results
After four months
| |
GP 1 |
GP 2 |
GP 3 |
GP 4 |
GP 5 |
GP 6 |
PR |
| Month 5 % of total |
2.2 |
0.92 |
1.96 |
0 |
0 |
2.03 |
1.36 |
Result - "had a chat" ranked 23rd with < 50 entries
1 GP down from 24% to 2%!
Month 1-5 figures
| Month % of total |
GP 1 |
GP 2 |
GP 3 |
GP 4 |
GP 5 |
GP 6 |
PR |
| Month 1 |
23.96 |
2.27 |
3.63 |
0 |
1.01 |
2.29 |
7.47 |
| Month 2 |
20.76 |
1.36 |
2.28 |
0 |
1.33 |
1.7 |
6.09 |
| Month 3 |
17.76 |
1.29 |
3.82 |
.55 |
1.33 |
1.23 |
5.05 |
| Month 4 |
2.17 |
1.06 |
3.26 |
0 |
0 |
0.88 |
1.48 |
| Month 5 |
2.2 |
0.92 |
1.96 |
0 |
0 |
2.03 |
1.36 |
Tips
- Anonymise data initially
- Celebrate success
- Gain whole team buy in
- Share at team meetings
