A Quality Assurance Indicator and Process for Measuring the Accuracy of Release of Information Requests
According to James F. Keenan (1993), questions about the accuracy of releases of information have assumed increasing prominence in several areas recently, such as the Persian Gulf war, the physical- and mental-health histories of public individuals, the identification of rape victims, and the threat of AIDS. The debates that have resulted have largely been guided by an important insight: the responsibilities that have been entrusted to particular professions contribute to the determination of whether release of information is considered right and proper. Ensuring such "right and proper" releases of information means having in place a system whereby quantifiable aspects of the underlying processes can be periodically reviewed to determine how well it is working. While the function goes by many names such as quality control, total quality management, and others, the healthcare profession in particular uses the term quality assurance to describe those methods used to monitor the outcomes of patient care activities, including the timely and accurate release of information. To this end, this paper provides a step-by-step analysis of how one such quality assurance monitor can be used to help improve patient healthcare outcomes, including the documentation required for this purpose, and graphic representations of how the process operates. A summary of the research will be provided in the conclusion.
Review and Discussion
Background and Overview. Financial and organizational strategies may inadvertently eliminate both needed and unneeded care as cost controls are introduced. Without quality monitoring, healthcare providers are unable to determine whether cost-control efforts are compromising quality. Therefore, quality assurance monitoring is an important tool for making optimal resource allocation decisions (Brook, Damberg, Ker & Mcglynn 1998). In their book, Ethics, Law and Medical Practice (1997), Kerry J. Breen, Stephen M. Cordner, and Vernon D. Plueckhahn note that the ethical concept of maintenance of confidentiality of information about patients was originally based on non-maleficence; in other words, the release of information could potentially do harm; however, the ethical concepts surrounding patient information is now clearly based on the principle of autonomy.
In other words, today, patients do not surrender their right to privacy and confidentiality by consulting a clinician. "Even if there were no ethical principle involved, for the practical reason of the need for trust to underpin a satisfactory doctor-patient relationship, confidentiality would remain pivotal" (Breen et al.:10). Notwithstanding the fundamental ethical principles involved in protecting confidential patient information, the healthcare facility's responsibilities certainly do not end there.
Today, there are a number of legal and ethical conflicts with the maintenance of patient confidentiality, the latter especially recognizable when a doctor possesses confidential information which, if released, might prevent harm or injury to others. Much more frequently in daily practice confidentiality is breached in several ways, knowingly (with implied consent), thoughtlessly, systematically or deliberately (without implied consent). For example, the sharing of information in hospitals with other staff or students breaches confidentiality, but normally implied consent can be safely assumed. In a thoughtless manner, many clinicians may inadvertently breach patient confidentiality in public discussions with colleagues or at clinical conferences.
This failure to maintain patient confidentiality is regarded as a systemic problem: "Systematically, institutional procedures can break confidentiality, by for example not keeping records secure or by the ready visibility of operating and admission lists" (Breen et al. 1997:11). Finally, some healthcare providers may intentionally breach confidentiality when seeking to learn more of the illness of one of their colleagues or certain public figures (Breen et al. 1997). Clearly, there are a number of ways in which patient confidentiality can be violated, but perhaps the most visible example of such methods is providing a copy of what was specifically requested in a release of information transaction to determine if it was, in fact, what was required to be provided.
According to Sheri A. Alpert (2003), "Informational privacy is often defined by how much personal information is available from sources other than the individual to whom it pertains" (301). The fewer opportunities people have to restrict access by others to their own personal information or to limit the amount of personal information they must give up to others (either voluntarily or by coercion), the less informational privacy they will enjoy (Alpert 2003). The appropriate release of information involves how and when personal information should be communicated or obtained and what uses of it will be made by others, and encompasses the collection, storage, use, maintenance, dissemination/disclosure, and disposition of personal information; in medical privacy settings, then, informational privacy is most frequently the interest that is at stake (Alpert 2003).
Setting of Random Audit and Methodology. One of the quality assurance monitors currently in place in the author's medical records unit is "Correct Information to be clipped and copied: Is the information requested correct? Yes/No?" To collect this information, a random audit of the release of information log book for a period of 30 days would be conducted to determine what was asked for against what was clipped and sent from the patient's chart. The threshold for this monitor is 99% accuracy in the documents or information provided to the requesting customer.
List the customers, outputs, measurable customer expectations and the gaps between expectations and performance. The customers of the release of information service may be both internal (other healthcare providers, administrative services or other agencies) or external (the patient and authorized family members). Regardless of their status as internal or external, all of these customers are directly impacted by the timeliness and accuracy of the medical information that is provided by the release of information service.
Furthermore, all patients will naturally expect their healthcare providers to tell them the truth (Breen et al. 1997). "It would be unusual," they say, "for an 'ethical' doctor to deliberately lie to patients but some doctors clearly have difficulty in discerning the difference between obfuscation and compassionate provision of information" (Breen, Cordner & Plueckhahn 1997:10). Likewise, other healthcare providers may seek medical test results or other information that concerns a specific current condition, and it would be inappropriate (and potentially illegal) to furnish these requestors with medical information that was not relevant or revealed information about the patient outside of the parameters established by the patient's permission for release.
Flow chart how the process is currently accomplished. Some aspects of the quality of patient care may be quantifiable; others are not (Drotar 1998). The flow chart shown in Figure 1 below illustrates the linear processes involved in accomplishing a typical ROI request:
Customer initiates ROI request
ROI Reception receives request and enters it in ROI log
ROI request it sent to ROI representative responsible for that alphabetic (patient name) or numeric (patient number or Social Security Number extension such as last four digits)
Patient medical records are retrieved, document or information is located and reproduced
ROI representative documents request in patient medical record and ROI log and sends document or information to customer
Figure 1. Linear Request for Information Flow.
Cause-and-Effect Diagram Illustrating the Current Process with Root Causes.
The cause-and-effect diagram illustrated in Figure 2 shows that both the ROI customer and/or the ROI representative can be the potential source of errors in completing a release of information request; for instance, the representative may select the incorrect information or document for copying, or the customer may request the incorrect information or document to be provided.
____> Inaccurate ROI
ROI Support Equipment
Figure 2. Cause-and-Effect Diagram for ROI Accuracy.
Other causes that tend to contribute to the higher incidence of error in the provision of ROI documents or information may be a computer or copy machine malfunction in the ROI service itself, or an internal ROI service method that does not support or provide the level of service that is required to meet the 99% threshold for this QA monitor.
Random Audit Data Collection Form. The data required for the random audit of the ROI records for the 30-day period would be accomplished using the form illustrated in Figure 3 below.
Random Audit of ROI Log (Threshold 99% Accuracy)
Accurate Info Provided?
Correct Information to be clipped and copied: Is the information requested correct? Yes/No?"
Figure 3. Sample Data Collection Form for Random Audit of ROI Log.
Customer Satisfaction Form. Data concerning the existing levels of patient satisfaction with the ROI function would be collected using the form illustrated in Figure 4 below. Each customer identified in the ROI log for the 30-day period under investigation would receive a copy of this survey, and the data analyzed using Excel or SPSS as appropriate. The responses in the open-ended segment would be collected verbatim and included in a periodic quality assurance summary for this monitor.
Customer Satisfaction Survey -- Release of Information (ROI)
The information I received from the Release of Information Service was exactly the information I requested.