Lillebælt Hospital streamlines clinical audits using SAS®
The Department of Orthopedic Surgery at Denmark's Lillebælt Hospital gave up resource-intensive, manual journal audits and initiated an IT solution that provides quality control of registrations in all patient records.
Previously, 1 percent of the patient records in the Department of Orthopedic Surgery at Vejle Hospital, a division of Lillebælt Hospital, were checked by random sampling during record audits four times a year by a surgeon and a secretary. But even the 160 records that were checked brought limited knowledge to those who made the mistakes, and most importantly, the quality control was time-consuming.
The hospital detected errors in 33 percent of the records it checked by random sampling. This meant that the hospital registered faulty or too few diagnoses or treatments. For example, when a patient with a thigh-bone fracture caught pneumonia during the hospitalization, the pneumonia and the treatment of it were too often not registered.
If data is faulty, the basis for decision making is also faulty. Therefore, the Clinically Correct Time-True Registration system makes sense beyond our department and hospital.
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Automated clinical audit
The department implemented the Clinically Correct Time-True Registration system, which automatically analyzes the records of all hospitalized patients. This is done by a text analytics-based solution from SAS. The software analyzes the surgeon’s dictation in the patient record and automatically registers the code that is connected to the diagnosis and the treatment. Some adaptation has been required to ensure that both Danish and Latin terms as well as abbreviations are interpreted correctly.
Lillebælt Hospital has adjusted and tested the system on an ongoing basis, and is ready to watch it stay the course on a larger amount of records. The hospital staff is evaluating the project to determine how well errors have been caught and fixed, and whether this is freeing surgeons to spend more time with patients.
"If the project meets our expectations, it can immediately be transferred to other orthopedic surgery departments in the Lillebælt Hospital group," said a member of the management team. "And with a few adjustments of codes and terminology, it can also be transferred to other surgical departments, where electronic patient records are already in use."
Lillebælt Hospital – Facts & Figures
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Information basis for other improvements
Due to this project, management at Lillebælt Hospital has prioritized the establishment of a database that can also be used for improvements in other areas. For example, the quality of clinical work can be improved because the procedures and diagnoses described in the electronic patient records are accessible in other systems, thereby forming a better basis for research and further diagnosis.
"Mistakes can be major or minor, significant or insignificant. But it is important to remember that all health care policy decisions are based on the statistics that each clinic contributes by registering data," said another member of the management team. "If data is faulty, the basis for decision making is also faulty. Therefore, the Clinically Correct Time-True Registration system makes sense beyond our department and hospital."