Point Values

General Criteria

Specific Data Calculation, Standards, and Compliance Rate Components

40 points 5 points for each type of calculation listed in the last column

Calculations necessary to find completion timeliness for the following on the next column

1. Release of information for all 20 requests (how many days it took to release the information requested)

1. Physician orders (how many days it took every physician to sign each of his or her orders)

1. History and physical dictation (how many days it took to dictate the H & P for each admission—subtract date of admission from the date of dictation)

1. History and physical transcription (how many days it took to transcribe the H & P—subtract date of dictation from the date of transcription)

1. Discharge summary dictation (how many days it took to dictate the DC for each admission—subtract date of discharge from the date of dictation)

1. Discharge summary signature (how many days it took to sign the DC—subtract date of discharge from the date signed)

1. Operative report dictation (how many days it took to dictate the OP report for each admission—subtract date of surgery from the date of dictation)

1. Operative report signature (how many days it took to sign the OP report—subtract date of surgery from the date signed)

 15 points

Standards* for the following on the next column

*Standards can be added in each worksheet applicable to the item being analyzed.

1. Completing ROI requests in the cases when records are on-site or off-site

1. Signing orders

1. Dictating a history and physical

1. Signing a discharge summary

1. Dictating an operative report

30 points 5 points for each of the items listed in the last column

Compliance rates based on the standards identified for the following on the next column

1. ROI requests

1. Physician orders

1. Dictation of History and Physical

1. Signing of Discharge Summary

1. Dictation of Operative Report

85 points total

Meets all of the components listed above

Point Value

Memo Components

10 points

Short introductory paragraph identifying the purpose and scope of the report

15 points

A paragraph highlighting areas that the hospital is in compliance with, including release of information, record documentation and completion, and incident reports. Paragraph should start with a summary sentence and then provide more details (including data) on each area the hospital is performing well.

25 points

A paragraph that addresses noncompliance, which should include the items below

· A summary of the areas of noncompliance.

· Any trends identified regarding a specific type of document (such as H & P or orders, certain physicians, core measures, etc.)

· Emphasis on two to three noncompliant items that are most serious or important in your opinion

· Clear details on all noncompliant items by using tables, graphs, or bullet points

25 points

A paragraph that explains at least three recommendations for improvement, which need to apply knowledge gained about performance improvement activities, tools, techniques, and information systems or other technology, as well as processes and working with people. Recommendations for improvement should be specific to issues identified in the prior paragraph.

5 points

Grammar and formatting. Memo format is required.

5 points

Content of the memo is well organized. Information in the paragraphs is well connected and supported with data. For example, if you identify an area of non-compliance, it will be expected to provide a recommendation for improvement for that particular issue.

85 points

Meets all of the components listed above

Category

Points

%

Description

Deliverable: Part 1

Part 1: Data Calculations, Standards, and Compliance Notes

Completion Timeliness Calculated for the Hospital

 40

Calculations necessary to find completion timeliness for each of the items listed above

Compliance Standards Identified 

 15

Standards for each item as listed above identified

Compliance Rates Calculated for the Hospital

 30

Compliance rates calculated based on the standards identified for each item listed

Total points

 85

 50%

Deliverable: Part 2

Part 2: Report

 Introduction

 10

Short introductory paragraph identifying the purpose and scope of the report

 Areas of Compliance

 15

Paragraph highlighting areas of compliance as described above

 Areas of Noncompliance

 25

Paragraph addressing areas of noncompliance as described above

 Recommendations

 25

Minimum of three recommendations for improvement with justification

 Grammar and Formatting

 5

Memo format is to be followed and writing should be free of grammar errors

 Organization and Cohesiveness

 5

Content is well organized, connected, and supported by data.

Total points for Week 7

 85

 50%

Total

 170

100

A quality project will meet or exceed all of the above requirements.