D258 Task 2 Process Improvement Plan Example

The Right Page in the Right Chart: A Lean Process Improvement Project Plan to Reduce Mis-Indexed Scanned Documents in a Newly Merged HIM Department

Student Name

Leavitt School of Health, Western Governors University

D258: Organizational Leadership in Healthcare, Task 2

Course Instructor

Month Day, Year

The Right Page in the Right Chart: A Lean Process Improvement Project Plan to Reduce Mis-Indexed Scanned Documents in a Newly Merged HIM Department

The Problem

After Summit University Health acquired Lakeshore Community Hospital, both hospitals' HIM scanning teams began working as one group of nine staff. Together they scan and index about 38,000 paper documents a month, mostly outside records, signed consent forms and forms from clinics that are not yet fully electronic. Each document must be attached, or indexed, to the correct patient, the correct encounter and the correct document type in the electronic health record.

A baseline audit of 2,000 documents indexed last month found 36 errors, a rate of 1.8%. Eight of those errors attached a document to the wrong patient, a rate of 0.4%, and the rest used the wrong encounter or document type. Applied to monthly volume, that is roughly 680 errors a month, including about 150 documents placed in another patient's chart. A misfiled document is a clinical risk, because a clinician may act on information about someone else or miss information that belongs to the patient. It is also a privacy risk, because patients increasingly read their own records online. In a survey of more than 22,000 patients who had read their ambulatory notes, 21.1% reported finding a mistake, and 42.3% of those considered it serious (Bell et al., 2020). A consent form or outside record that appears in the wrong patient's portal is both an error and a disclosure.

Goal

Within six months, reduce wrong-patient indexing to fewer than 1 per 10,000 documents (0.01%) and total indexing errors to below 0.5%, while keeping the time from receipt of a document to its availability in the record at or under one business day.

Methodology: Lean

The project will use Lean, an approach that improves a process by asking what the people served by it actually need, mapping how work actually flows, removing waste and building quality into each step so errors cannot easily happen. Lean has been increasingly adapted to health care over the past two decades, and a comprehensive review of the research described its growing use as a way to improve value in health services (D'Andreamatteo et al., 2015). Lean suits this problem because indexing errors are a process defect, not a lack of effort, and because the process can be observed and changed by the people who do the work.

Applying the Lean Steps

Step 1: Define value. For clinicians and patients, value means the right document in the right chart, available within one business day. Anything that does not contribute to that, such as waiting, rework or duplicate handling, is waste.

Step 2: Map the value stream. The team will follow documents from arrival to availability at both hospitals and draw a single map. Early observation already shows differences: Lakeshore scans in large mixed batches at the end of each week, while Summit scans daily but relies on a quality check of only 10% of documents. At both sites, staff search for the patient by typing a last name, then choose from a list, which invites selection errors when names are similar. Misspellings and name variations are among the most common causes of patient identity discrepancies (Just et al., 2016).

Step 3: Find the root causes. Using the map and the audit errors, the team will build a cause-and-effect diagram. Likely causes include name-only searches, batches that mix several patients' documents, the absence of barcodes on internally generated forms and frequent interruptions at the indexing workstation.

Step 4: Build quality in. The main improvement is mistake-proofing. Clinics and units will print a barcoded cover sheet from the electronic health record for each patient and encounter before sending paper to HIM, so that the scanner reads the patient and encounter automatically. For outside records without a cover sheet, the indexing screen will require two identifiers, name and date of birth, to match before a document can be filed. Batches will contain one patient's documents only, and indexing will move to a quiet workspace with a no-interruption rule during indexing blocks.

Step 5: Create flow. Both sites will scan daily in small batches rather than weekly, which reduces waiting and makes errors easier to trace to their source.

Step 6: Standardize and pursue perfection. The team will write one standard work procedure for both sites, display daily error counts on a visual board and hold a short improvement meeting each month to review new errors and test further changes.

Team and Roles

Sponsor: HIM director, who approves resources and removes barriers. Project lead: an HIM supervisor trained in Lean, who runs meetings and keeps the timeline. Members: two scanning specialists from Lakeshore and two from Summit, so that both former teams shape the new process; a clinic registration supervisor, since cover sheets begin at the front desk; an IT analyst to configure barcodes and the two-identifier rule; and the privacy officer, who reviews every wrong-patient error as a potential privacy incident. Mixing the two former teams is deliberate. Working on a shared problem is one of the fastest ways to build the common culture the merger needs.

Timeline

Weeks 1 to 2: charter approved, baseline audit completed. Weeks 3 to 5: value stream map and root cause analysis. Weeks 6 to 12: pilot barcoded cover sheets and two-identifier indexing with three Lakeshore clinics and the Summit surgery center. Weeks 13 to 18: spread to all clinics and units. Weeks 19 to 24: measure, standardize and hand off to daily operations.

Measures of Success

The outcome measure is wrong-patient indexing errors per 10,000 documents, from a weekly audit of 500 randomly selected documents. The process measures are the percentage of documents arriving with a barcoded cover sheet (target 90% of internal documents) and the total indexing error rate. The balancing measures are indexing productivity in documents per hour and the time from receipt to availability, so that accuracy is not bought with delays.

Sustaining the Gains

Once the goal is met for two consecutive months, the audit will move from weekly to monthly, the standard work will be built into training for all new scanning staff, and cover sheet use will be reported to clinic managers each month. Any wrong-patient error will continue to trigger a review by the privacy officer and the project lead, so that a new cause is found and fixed quickly.

References

Bell, S. K., Delbanco, T., Elmore, J. G., Fitzgerald, P. S., Fossa, A., Harcourt, K., Leveille, S. G., Payne, T. H., Stametz, R. A., Walker, J., & DesRoches, C. M. (2020). Frequency and types of patient-reported errors in electronic health record ambulatory care notes. JAMA Network Open, 3(6), e205867. https://doi.org/10.1001/jamanetworkopen.2020.5867

D'Andreamatteo, A., Ianni, L., Lega, F., & Sargiacomo, M. (2015). Lean in healthcare: A comprehensive review. Health Policy, 119(9), 1197-1209. https://doi.org/10.1016/j.healthpol.2015.02.002

Just, B. H., Marc, D., Munns, M., & Sandefer, R. (2016). Why patient matching is a challenge: Research on master patient index (MPI) data discrepancies in key identifying fields. Perspectives in Health Information Management, 13(Spring), 1e.