Hendrickson: Take steps to make sure physicians follow report submission guidelines

It seems there are ongoing issues with some practitioners not completing their records in a timely matter.  Some of these record completion dates and times are necessary in order to be in compliance with accreditation standards, so it is up to the medical facility to craft a way for its practitioners to follow and be in compliance with the recommended guidelines. Our committees have determined that the process currently in place does not get the attention of physicians who consistently show up on the delinquency reports.  

We recently worked on revising our Timeliness of Completing History and Physical and Operative Reports policy to the effect that if the ongoing review of timeliness data completed discloses that if any practitioner has fallen below the compliance rate (set at 90%) for the timeliness of completing medical H & P Reports of physical examination or the operative reports during their 2-year reappointment the following action will be taken:

One quarter: Practitioner will receive a letter requesting improvement

Two quarters: Practitioner will receive a second letter requesting improvement and notification that a drop in compliance in any subsequent quarter, further action will be taken per policy and the respective Vice-Chair of the practitioner’s department will discuss the matter with the practitioner. 

Three quarters: Practitioner will be required to appear before the peer review committee and provide a written plan to improve timeliness completion and will be assessed a fee of $250.  If the practitioner is not in compliance at the time of appearance before the Committee, notification will be sent to the President/CEO with a request to issue a temporary suspension as provided for in the bylaws.  

Four quarters:  Practitioner will be required to appear before the credentials committee and provide a written plan to improve timeliness completion and assessed a fee of $500.  If the practitioner is not in compliance at the time of appearance before the Committee, notification will be sent to the President/CEO with a request to issue temporary suspension as provided for in the bylaws.  

Five quarters: Practitioner shall be referred in the manner provided by the medical staff bylaws for corrective action. 

This policy change will be presented from the credentials committee to the medical executive committee and to the board of directors for final approval.