This document describes a quality assessment project conducted by Linda Cheung on the forms compliance process at Heritage Valley Health System. The project analyzed 25 forms for errors like incorrect abbreviations and inconsistencies. Only 21 forms were found to be fully compliant. The purpose of the project was to understand the root causes of errors in forms given to the hospital's Forms Committee for review. The document outlines the steps of the FOCUS-PDSA model used to guide the project, including defining the problem, organizing a team, data collection and analysis.

1.
Quality
Assessment
Project
Linda
Cheung
Spring
14

2. 2
Introduction
This
semester
I
was
fortunate
enough
to
have
my
clinical
education
at
Heritage
Valley
Health
System
in
Sewickley.
There
were
many
areas
of
the
HIM
department
that
I
was
exposed
to
during
my
clincals
at
Sewickley,
but
a
large
amount
of
time
was
concentrated
on
the
Forms
Committee
that
my
supervisor,
Tina
Wood,
had
taken
over
responsibility
for.
The
Forms
Committee
is
composed
of
a
group
of
representatives
from
various
departments
(from
both
Sewickley
and
Beaver
sites)
that
meet
bimonthly
via
webcam
to
discuss
the
status
of
various
forms;
editing
and
reviewing
them
to
ensure
that
they
are
compliant
with
not
only
the
hospital,
but
also
Joint
Commission,
before
finally
approving
them
and
introducing
them
into
the
Heritage
Valley
Health
System
facility.
These
forms
range
anywhere
from
Physician’s
Orders
forms
to
alcohol
abuse
surveys.
Mark,
who
had
clinical
with
me,
and
I
had
the
chance
to
sit
in
on
these
meetings
every
week
and
Tina
would
give
us
each
a
copy
of
all
the
forms
before
the
meeting,
so
that
we
could
go
through
them
ourselves
and
look
for
mistakes.
Because
Forms
Committee
was
an
activity
that
Mark
and
I
would
take
part
in
every
week
we
were
at
clinical,
we
both
became
very
familiar
with
the
process
the
hospital
went
through
to
approve
forms,
and
also,
in
a
way,
invested
to
the
progress
of
these
forms.
It
was
because
of
this
that
I
decided
to
base
my
Quality
Assessment
project
on
the
compliancy
of
forms
at
Heritage
Valley
Health
System.
Purpose
The
compliancy
of
forms
is
a
very
large
part
of
having
an
efficiently
operating
health
system
anywhere.
The
significance
of
having
compliant
forms
at
Heritage
Valley
Health
System
–
Sewickley
is
no
exception.
There
were
many
issues
that
I
found
were
quite
constant
in
the
forms
in
discussion.
The
three
categories
I
could
place
the
majority
of
the
issues
found
would
be
1.)
Incorrect
or
inaccurate
abbreviations,
2.)
Inconsistencies
throughout
a
single
form
and/or
multiple
forms
and
3.)
General
spelling
and
grammar
errors.
During
meetings
there
would
be
moments
of
miscommunication
between
the
two
sites,
confusion
and
disagreement,
and
I
also
believe
that
the
level
of
efficiency
to
complete
these
forms
was
affected
by
the
miscommunication,
and
thus
the
progress
in
general
was
deterred.
Approach
As
previously
stated,
I
conducted
this
study
by
gathering
forms
used
at
Heritage
Valley
Health
System
and
analyzing
the
forms
for
their
errors
and
inconsistencies.
In
order
to
properly
assess
all
aspects
of
the
intended
goal,
I
followed
the
FOCUS-­‐PDSA
model.
The
FOCUS-­‐PDSA
Model:
F-Find/define the problem

3. 3
O-Organize a team
C-Clarify the process
U-Understand the process
S-Select the improvement
P-Plan the improvement
D-Do the improvement
S-Study/check the improvement
A-Act on results
Focus/Define
the
Problem
The
first
step
according
to
the
FOCUS-­‐PDSA
model
is
to
properly
define
the
problem.
The
purpose
of
this
study
is
to
discover
the
root
of
the
issue
of
why
the
forms
that
are
given
to
the
Forms
Committee
have
the
errors
that
they
do.
In
order
to
do
this,
I
constructed
an
Excel
spreadsheet
and
listed
four
categories
in
which
the
errors
found
in
twenty-­‐five
randomly
selected
forms
could
be
defined.
Along
with
the
four
categories,
I
added
an
additional
column
that
listed
the
proof
number
(the
number
of
times
the
form
had
previously
been
reviewed)
and
another
column
stating
whether
or
not
the
form
was
compliant.
Figure
1:
Forms
Worksheet
As
depicted
by
Figure
1,
it
is
evident
that
the
biggest
issue
that
arose
out
of
all
the
forms
as
a
collective
unit
was
due
to
wrong
abbreviations.
Following
that,
many
of
the
forms
showed
a
lack
of
consistency
in
the
wording
or
abbreviations
that
they
used.
Out
of
all
twenty-­‐five
forms,
only
twenty-­‐one
were
compliant.

4. 4
Organize
a
Team
Heritage
Valley
Health
System
has
a
Forms
Committee
that
handles
all
the
matters
that
deal
with
forms
within
their
health
system.
The
members
range
from
my
own
supervisor,
the
head
of
the
Forms
Committee
and
Medical
Records
department,
Tina
Wood,
to
representatives
of
other
departments
of
the
hospital,
such
as
nursing,
surgery
and
pharmacy.
Before
Ms
Wood
took
over
the
Forms
Committee,
the
members
beforehand
did
not
have
an
efficient
system
for
looking
over
the
forms
and
making
sure
they
were
compliant
with
Joint
Commission
and
the
hospital.
Because
of
this,
when
Ms
Wood
took
over
the
committee,
they
had
extra
ground
to
cover
from
the
previous
Forms
Committee.
Between
the
Forms
Committee
members
at
Heritage
Valley
Health
System
Sewickley
and
Heritage
Valley
Health
System
Beaver,
who
attend
the
meeting
via
webcam,
every
member
has
something
to
offer
to
the
problems
with
the
forms
and
is
willing
to
voice
their
opinion.
There
are
no
members
that
take
a
back
seat.
This
is
important
in
a
team;
that
all
the
members
contribute.
Clarify
and
Understand
the
Problem
Most
problems
that
had
to
do
with
the
abbreviations
sprouted
from
either
certain
letters
being
capitalized
when
they
ought
not
be,
as
something
as
small
as
capitalization
does
indeed
affect
the
meaning
of
an
abbreviation,
to
lack
of
punctuation
between
letters,
to,
in
general,
the
illegal
abbreviations
on
the
Do
Not
Use
List.
The
issue
with
consistency
varied
from
within
a
single
form,
to
from
form
to
form.
For
example,
a
single
form
might
have
“grams/mL”
and
“G/mL”
in
the
same
document.
Or,
one
form
could
feature
one
version,
while
other
forms
would
have
the
other
version.
This
causes
confusion
and
in
general
does
not
look
as
clean
as
having
a
universal
word
or
phrase
to
use
within
all
the
different
forms.
As
for
spelling
and
grammar,
many
of
the
mistakes
were
simple
mistakes
that
could
easily
be
overlooked,
such
as
“then”
versus
“than”
or
“effect”
versus
“affect”.
Formatting
problems
arose
from
areas
where
the
form
was
not
as
clear
as
it
could
be,
and
from
where
problems
would
be
able
to
arise.
Examples
of
this
could
be
an
unclear
area
for
the
physician
to
write
his
notes
or
even
repetitive
things,
such
as
two
places
on
a
single
form
to
write
the
date.
On
the
following
page,
Figure
2
shows
the
amount
of
times
each
issue
arose
out
of
the
twenty-­‐one
documents
that
showed
discrepancies.
The
four
empty
areas
represent
the
four
documents
that
were
compliant.

5. 5
Figure
2:
Form
Compliancy
Issues
in
Each
Document
From
this
graph,
one
can
see
there
is
noticeably
more
blue
than
any
of
the
other
colors,
and
that
red
is
quite
prominent
as
well.
Benchmarks
and
Standards
The
data
that
was
uncovered
after
analyzing
the
forms
was
categorized
according
to
Joint
Commission
standards,
Heritage
Valley
Health
System
Form
Checklist,
the
Do
Not
Use
Abbreviations
List
and
the
ISMP’s
Guidelines
for
Standard
Order
Sets.
The
benchmark
set
by
Joint
Commission
is
100%
compliant.
Because
forms
had
not
been
reviewed
annually
up
to
this
point
at
Heritage
Valley
Health
Systems,
as
Joint
Commission
states
they
should
be,
it
adds
more
work
to
those
in
the
Forms
Committee
today.
Since
my
project
is
based
on
forms
under
speculation,
it
is
expected
that
most
of
them
are
not
compliant,
as
there
has
to
be
some
reason
that
they
are
being
reviewed
and
updated.
However,
there
are
those
forms
I
came
across
that
were
approved
during
meeting.
Referencing
the
Excel
worksheet
with
the
twenty-­‐five
forms
I
reviewed,
the
chart
on
the
following
page
depicts
the
breakdown
of
the
number
of
compliant
to
not
compliant
forms
that
I
pulled
and
reviewed.

6. 6
Figure
3:
Form
Compliancy
Status
As
depicted,
the
number
and
percentage
of
forms
under
review
that
are
still
not
compliant/being
edited
versus
the
ones
that
are
properly
updated/approved
is
much
less
than
what
Joint
Commission
wants.
I
do
believe
that
if
this
benchmark
were
compared
to
all
of
the
forms
at
Heritage
Valley
Health
System,
the
majority
would
be
compliant.
Select
the
Major
Cause
After
reviewing
the
forms
and
constructing
the
Excel
spreadsheets
and
creating
various
graphs,
it
was
quite
simple
to
classify
which
issue
was
the
most
common
within
the
forms
at
Heritage
Valley
Health
System.
As
stated,
it
is
evident
that
wrong
abbreviations
are
the
most
prominent
and
biggest
contributor
in
regards
to
the
compliancy
issues
within
the
forms
at
Heritage
Valley
Health
System.
A
lot
of
this
has
to
do
with
the
ease
of
making
mistakes
and
overlooking
typos.
It
is
also
quite
possible
that
authors
of
forms
might
assume
what
an
abbreviation
for
something
is,
thinking
that
it
is
obvious,
before
a
reviewer
or
the
Forms
Committee
realizes
that
it
is
incorrect.
Human
error
can
very
easily
be
present
when
abbreviations
in
forms
are
the
subject
at
hand.
A
simple
typo
or
an
accidental
capital
letter
could
be
the
difference
between
one
abbreviation
versus
another.

7. 7
In
the
figure
on
the
following
page,
a
pie
chart
gives
a
visual
representation
of
the
breakdown
of
the
different
causes
linked
to
the
form
compliancy
issues
at
Heritage
Valley
Health
System.
As
you
can
see,
the
blue
(abbreviations)
section
takes
up
almost
half
of
the
pie
chart.
Figure
3:
Percent
Breakdown
of
Compliancy
Issues
Plan
After
spending
time
in
Forms
Committee
every
other
Thursday
and
having
a
first
hand
experience
of
what
takes
place
during
these
meetings
in
conjunction
with
being
able
to
go
through
and
analyze
various
forms
under
speculation
of
Forms
Committee,
I
was
able
to
grasp
a
strong
understanding
and
opinion
on
how
the
Forms
Committee
and
in
general,
form
making,
could
be
streamlined
and
made
to
run
more
efficiently.
Actions
that
I
thought
could
help
in
adapting
a
more
efficient
system,
were
to
help
formulize
a
more
standardized
and
organized
way
of
evaluating
and
reviewing
forms
through
creating
an
environment
where
all
the
standards
and
rules
related
to
the
forms
were
understood
and
well
known
throughout
the
Forms
Committee,
and
to
just
remind
individuals
to
proofread
their
work.
Through
these
actions,
the
target
goal
of
having
all
compliant
and
clean
forms
at
Heritage
Valley
Health
System
can
be
achieved.
My
recommendations
were
to
hire
at
least
three
new
members
or
even
create
a
subcommittee
that
is
meant
solely
to
review
the
forms.
Many
mistakes
or

8. 8
typos
could
have
been
caught
much
easier,
but
due
to
the
fact
that
everyone
in
Forms
Committee
already
has
responsibilities
in
their
department,
not
everyone
has
adequate
time
to
sit
down
and
scrutinize
forms
after
a
long
day
at
work,
especially
if
there
are
already
pressing
matters
within
their
own
departments.
By
bringing
in
new
members
or
creating
a
subcommittee
that
has
no
other
obligations,
it
would
lessen
the
load
on
those
that
have
other
responsibilities
whose
time
commitment
may
be
restricted,
and
also
give
pairs
of
fresh
eyes
a
chance
to
look
over
the
forms
and
catch
things
that
could
have
been
overlooked.
Members
could
also
correct
errors
as
soon
as
they
are
found,
as
opposed
to
waiting
until
Forms
Committee
meetings.
As
the
Forms
Committee
stands,
authors
and
reviewers
of
forms
will
bring
up
certain
errors
during
meeting,
and
while
it
may
be
a
positive
thing
to
discuss
the
issue
with
others,
it
takes
up
a
lot
of
time
that
could
be
used
to
touch
on
another
form.
If
the
mistake
is
corrected
when
it
is
found,
the
person
who
found
the
error
could
just
mention
the
change
during
meeting,
and
then
move
on
from
there.
If
this
system
is
put
in
place,
a
lot
of
time
would
be
saved
and
be
sectioned
more
efficiently.
More
forms
would
be
approved
and
covered
during
the
hour
that
Forms
Committee
meeting
covers.
Another
recommendation
is
to
assign
specific
form(s)
to
a
specific
person
or
persons.
This
way,
every
one
knows
whom
to
consult
for
any
given
form.
This
would
reduce
confusion
and
trafficking
of
e-­‐mails
to
figure
out
whom
to
contact
for
whichever
form.
Time
and
energy
would
both
be
saved
this
way.
Currently,
every
form
has
an
owner,
although
a
problem
that
I
noticed
is
that
there
is
general
confusion
as
to
what
form
belongs
to
which
person.
This
leads
me
to
another
suggestion,
the
implementation
of
an
online
site
where
members
of
the
Forms
Committee
can
log
on
and
see
which
form
belongs
to
which
person.
An
example
would
be
sharing
a
Google
doc
link.
That
way,
along
with
stating
who
has
what
form,
as
updates
are
being
made,
the
person
making
updates
can
go
along
and
update
it
on
Google
docs
for
all
to
see.
Below
is
an
example
of
what
this
spreadsheet
could
look
like.

9. 9
Making
extra
strides
toward
being
confident
that
each
reviewer
has
a
clear
understanding
of
what
the
standards
and
rules
are
could
make
all
the
difference
when
it
comes
starting,
developing
and
finishing
a
form.
Each
member
should
be
distributed
a
copy
of
all
the
rules
and
standards
that
need
to
be
followed.
These
copies
should
be
consulted
each
time
a
form
is
being
made.
Lastly,
something
as
simple
as
remembering
to
proofread
could
save
a
form
from
having
to
go
through
the
tedious
cycle
of
being
edited
for
a
minor
error.
Each
reviewer
should
double
check
and
proofread
one
more
time,
even
after
they
think
the
form
is
compliant
and
consistent,
and
that
those
few
extra
minutes
glancing
over
the
form
could
save
hours
to
even
days
of
unnecessary
e-­‐mail
exchange
and
processing.
There
should
be
no
reason
for
a
proof
number
higher
than
three
on
any
form.
Do
Since
starting
Clinical
Education
at
Heritage
Valley
Health
System
in
Sewickley,
the
Forms
Committee
has
become
more
efficient
after
each
visit.
The
two
most
recent
and
my
final
meetings
that
I
attended,
on
March
20,
2014
and
April
3,
2014,
passed
forms
to
be
printed
and
also
concluded
early;
two
things
that
rarely
happened
during
the
meetings
attended
during
the
start
of
my
clinicals
here
at
Sewickley.
It
might
not
be
seen,
but
it
is
very
obvious
that
a
lot
of
work
is
being
done
behind
the
scenes
to
facilitate
the
process
of
approving
forms
that
are
completely
compliant
with
the
Joint
Commission.
The
Forms
Committee
has
also
decided
to
start
correcting
forms
as
mistakes
are
being
found,
rather
than
waiting
for
the
meeting.
By
looking
over
at
these
forms
before
meetings
start,
the
time
spent
on
each
form
was
shortened
greatly
and
the
meetings
even
concluded
before
the
hour
passed.
Study
The
result
of
implementing
even
one
of
the
recommendations
made
the
meeting
run
more
smoothly
than
before
and
more
forms
were
approved
those
days
than
had
been
on
any
previous
days
that
I
attended
the
Forms
Committee.
Every
time
Forms
Committee
meets,
progress
is
being
made
and
clearer
understanding
on
how
to
achieve
the
target
goal
becomes
closer
and
more
in
sight.
Heritage
Valley
Health
System
a
few
years
back
had
switched
vendors,
causing
a
lot
of
back
track
due
to
having
to
send
all
of
their
forms
to
R.R.
Donnelly,
their
new
and
current
vendor.
Even
with
the
extra
load,
the
increase
in
productivity
during
meetings
has
improved
every
time
and
steps
are
being
made
toward
the
right
direction.
Action
The
Forms
Committee
should
form
a
subcommittee
dedicated
to
reviewing
the
forms,
especially
those
belonging
to
physicians,
for
they
are
better
suited
to
look
for
small
errors
that
can
easily
be
missed
by
the
members
who
do
not
have
a
lot
of

10. 10
time
to
dedicate
to
reviewing
forms
or
have
other
matters
at
hand.
Forms
should
be
reviewed
prior
to
attending
the
meeting
and
mistakes
should
be
marked
accordingly.
That
way,
when
the
form
is
discussed,
there
will
not
be
time
wasted
on
reviewing
it
too
in
depth
there,
because
most
if
not
all
of
the
errors
were
already
caught
when
it
was
being
reviewed
beforehand.
Currently,
there
is
some
type
of
distribution
of
what
forms
belong
to
what
person,
but
it
could
be
neater.
I
think
that
there
should
be
an
internet-­‐based
spreadsheet,
such
as
the
Google
doc
suggested
earlier,
that
is
accessible
only
be
Forms
Committee
and
subcommittee
members
and
also
a
printed
monthly
or
bimonthly
e-­‐mail
so
that
there
is
an
updated
hard
copy
if
ever
someone
is
working
on
forms
without
the
internet.
This
spreadsheet
should
at
least
state
the
forms
that
are
currently
being
written
or
reviewed,
the
proof
number,
and
a
name
and
e-­‐mail
address
of
the
person
who
is
in
charge
of
that
form.
This
would
diffuse
much
of
the
communication
issues
that
take
place
when
the
vendor
does
not
know
what
the
Forms
Committee
member
is
working
on
who
does
not
know
what
the
Information
Systems
person
in
charge
of
Allscripts
is
working
on.
Everyone
would
be
able
to
keep
up
with
the
progress
as
a
collective
unit
and
also
know
that
revisions
are
being
made
on
the
most
recent
proof.
In
addition
to
working
together
as
a
group,
I
would
like
to
see
every
member
of
the
Forms
Committee
have
a
copy
of
the
standards
and
rules
by
Joint
Commission,
ISMP
and
Heritage
Valley
Health
System
at
their
disposal,
so
that
they
may
be
able
to
consult
them
whenever
they
are
the
slightest
bit
unsure.
I
would
even
recommend
having
the
rules
and
regulations
laminated
and
posted
in
different
parts
of
the
hospital,
especially
in
the
offices
of
those
in
the
Forms
Committee.
Also,
proofread.
If
members
were
just
reminded
to
proofread
whenever
they
have
a
spare
minute,
a
lot
of
trouble
could
be
avoided
and
time
could
be
saved.
Heritage
Valley
Health
System
has
been
a
great
experience
for
me
to
learn
about
the
good
and
bad
of
“the
real
world”.
This
hybrid
hospital
is
full
of
hard
workers
that
just
have
a
lot
of
catching
up
to
do
from
previous
form
undertaking.
I
believe
that
all
of
these
recommendations
and
actions
are
in
an
effort
for
a
smoother
system
at
Heritage
Valley
Health
System
and
could
bring
success
as
an
end
result.