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439 Application of Quality Control Circle in ICD Coding of Medical Records Wang Peijia, Jin Hao and Qian Li’na Zhongshan Hospital Affiliated to Fudan University, Shanghai, P. R. China Citation: Wang P, Jin H, Qian L. Application of Quality Control Circle in ICD Coding of Medical Records. Chin Med Rec Engl Ed, 2013; 1(10): 439–41. Quality control circle (QCC), also known as “quality team”, was founded by Dr. Kaoru Ishikawa from Japan in 1962. It is an optimum management activity of enterprises for autonomous management of grass-roots employees, qual- ity control of all staff and continuous improvement. Its effective implementa- tion is good for establishment of enterprise quality culture, improvement of working efficiency, enhancement of operation, operational performance and the competitiveness of the enterprise [1]. Information from the medi- cal record department is the main source for the National Health Office to count information, and is also basis for dealing with medical malpractices and medical insurance payments [2]. In recent years, hospitals, patients, health insurance and the judiciary departments increasingly attach impor- tance to the medical record information, the correctness of ICD coding is not only related to the retrieval use of medical record information, but also the accuracy of the hospital counting information, it is very essential to ensure the correctness of ICD coding [3]. erefore, the “reduction of ICD-coding error rate in medical record” is selected as the theme of the QCC activity. 1. Data and methods 1.1 Data. Medical record data of the discharged patients from July to August 2012 before the QCC activity and November to December 2012 after the Address correspondence to: Wang Peijia, Zhongshan Hospital Affiliated to Fudan University, Shanghai 200032, P. R. China. Chinese Medical Record English Edition, 2013; 1(10): 439–441 © 2013 Chinese Medical Record Association ISSN 2325-6176 online DOI: 10.3109/23256176.2013.865901 Abstract Objective. To decrease the error rate of ICD coding of medical records and improve the performance level of medical records staff and their management efficiency. Method. The quality control circle activities are applied to the ICD coding of medical records and all the activities are implemented according to the ten steps of the activities of the quality control circle. The coding error rates are compared between the data before and after the activity, and the improvement degree is calculated, the tangible results and the intangible results are assessed. Result. After the quality control circle activities are conducted, the number of the cases with coding errors is decreased obviously and the ICD-coding error rate of the medical records is decreased from 24.57% before the activities to 8.13% after the activities, with an improvement rate of 66.90%. The staffs obviously improve themselves in the aspects of skill application in the quality control circle activities, team cohesiveness, learning initiative and sense of group honor. Conclusion. The management level and the working skill of the staff are improved by the quality control circle activities, and the working procedures are standardized and the error rate of the ICD coding in the medical records is decreased, thus the coding quality of medical records is improved. Key words: Quality control circle; ICD coding; Reason of error coding Chinese Medical Record English Edition Downloaded from informahealthcare.com by Technische Universiteit Eindhoven on 11/17/14 For personal use only.

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Page 1: Application of Quality Control Circle in ICD Coding of Medical Records

439

Application of Quality Control Circle in ICD Coding of Medical Records Wang Peijia , Jin Hao and Qian Li ’ na

Zhongshan Hospital Affi liated to Fudan University, Shanghai, P. R. China

Citation: Wang P, Jin H, Qian L. Application of Quality Control Circle in ICD Coding of Medical Records. Chin Med Rec Engl Ed, 2013; 1(10): 439 – 41.

Quality control circle (QCC), also known as “ quality team ” , was founded by Dr. Kaoru Ishikawa from Japan in 1962. It is an optimum management activity of enterprises for autonomous management of grass-roots employees, qual-ity control of all staff and continuous improvement. Its eff ective implementa-tion is good for establishment of enterprise quality culture, improvement of working effi ciency, enhancement of operation, operational performance and the competitiveness of the enterprise [1]. Information from the medi-cal record department is the main source for the National Health Offi ce to count information, and is also basis for dealing with medical malpractices and medical insurance payments [2]. In recent years, hospitals, patients, health insurance and the judiciary departments increasingly attach impor-tance to the medical record information, the correctness of ICD coding is not only related to the retrieval use of medical record information, but also the accuracy of the hospital counting information, it is very essential to ensure the correctness of ICD coding [3]. Th erefore, the “ reduction of ICD-coding error rate in medical record ” is selected as the theme of the QCC activity.

1. Data and methods

1.1 Data. Medical record data of the discharged patients from July to August 2012 before the QCC activity and November to December 2012 after the

Address correspondence to: Wang Peijia, Zhongshan Hospital Affi liated to Fudan University, Shanghai 200032, P. R. China.

Chinese Medical Record English Edition, 2013; 1(10): 439–441© 2013 Chinese Medical Record AssociationISSN 2325-6176 onlineDOI: 10.3109/23256176.2013.865901

Abstract

Objective . To decrease the error rate of ICD coding of medical records

and improve the performance level of medical records staff and their

management effi ciency. Method. The quality control circle activities are

applied to the ICD coding of medical records and all the activities are

implemented according to the ten steps of the activities of the quality

control circle. The coding error rates are compared between the data

before and after the activity, and the improvement degree is calculated,

the tangible results and the intangible results are assessed. Result. After

the quality control circle activities are conducted, the number of the

cases with coding errors is decreased obviously and the ICD-coding error

rate of the medical records is decreased from 24.57% before the activities

to 8.13% after the activities, with an improvement rate of 66.90%. The

staff s obviously improve themselves in the aspects of skill application

in the quality control circle activities, team cohesiveness, learning

initiative and sense of group honor. Conclusion . The management level

and the working skill of the staff are improved by the quality control

circle activities, and the working procedures are standardized and the

error rate of the ICD coding in the medical records is decreased, thus the

coding quality of medical records is improved.

Key words: Quality control circle; ICD coding; Reason of error coding

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Page 2: Application of Quality Control Circle in ICD Coding of Medical Records

Copyright © 2013 Editorial Board of Chinese Medical Records

440 Wang Peijia et al.

QCC activity and the ICD coding error checking records of the medical statistical department are collected. Data before and after the QCC activity are counted.

1.2 Methods 1.2.1 Circle formation and training. Th ere are ten

circle members in the QCC of the medical statistical department, with one circle leader, one assistant and one secretary. One training counselor is invited to train related knowledge of the QCC and guide the activity process. Th rough voting of all circle members, the circle name and circle logo of the activity are selected and confi rmed.

1.2.2 Selection of activity theme and formulation of activity plan. Many problems occurring in the work are chosen as themes by the circle members in a brain storming manner. Th e theme is evaluated from four aspects, namely signifi cance, urgency, circle capability and high-level policy by using an evaluation method, and the chosen themes are scored. After summarizing and ranking, the fi rst rank of “ reduction of ICD-coding error rate in medical record ” is fi nally determined as the theme of the activity. After the theme of the activity is confi rmed, the circle director calculates the time needed in each step of the activity, the quality control skill and the main responsible staff in each step to form a Gantt diagram, which is approved by the confi rmation of all circle members.

1.2.3 Status grasping. In the status grasping phase, 704 of 14,097 medical records of inpatients discharged from July to August 2012 are randomly sampled and checked, accounting for 5%, wherein 173 medical records have ICD coding errors, and the error rate is 24.57%. Th e circle members discuss and analyze the causes of the coding errors and calculate the constitu-ent ratio of the cause of the errors. Th ey fi nd that the errors caused by primary and secondary diagnosis selection errors and negligence of medical record con-tents account for 88% of all error causes. Th us the ICD coding errors are mainly caused by the two reasons, referring to the 80/20 principle, which is basically con-sistent with related literature reports through inquiry [4], therefore, improvement of the errors caused by primary and secondary diagnosis selection errors and negligence of medical record contents is used as the emphasis of the QCC activity.

1.2.4 Target setting. Th e error rate before activity is 24.57%, the improvement degree is set as improve-ment emphasis � circle capability � 88% ∗ 60% � 52.8% , target value � status value � improvement value � status value-(status value � improvement degree) � 24.57% � 24.57% � 52.8% � 11.6% , that is, the errors caused by primary and secondary diagnosis selection errors and negligence of medical record contents are improved to reduce the cases of ICD coding errors. Th e target is to reduce the ICD-coding error rate to 11.6%.

1.2.5 Target analysis and countermeasure formulation. After the goal is set, the circle members look for various factors which possibly result in the cod-ing errors caused by primary and secondary diagnosis selection errors and negligence of medical record con-tents which results from four aspects, namely people, methods, equipment and working systems, and then the members discuss and analyze the factors by using a fi shbone diagram method to determine the main factor. Aiming at the analyzed and determined main factors, the circle members propose various counter-measures and create four countermeasures by using the evaluation method: (1) standardization of medical record reading process, the medical record home page, discharge summary, resident admit note, daily progress note and inspection reports of each medical record must be read, if the patient is subjected to operation, the surgical records and pathology reports must be checked; (2) uniformity of recording and sharing of the diffi cult (or infrequent) ICD coding, when the codes are understood diff erently, the etiology and pathology are commonly analyzed and understood by looking up references and consulting with experts, the correct coding is found according to the coding principle and the coding step; (3) strengthening communication and exchange with colleges, the coders help each other to check, periodically summarize and discuss and learn and share the working experience; (4) a specifi c proof-reading retrieval module is increased in the medical-record-management system, the suspicious medical records which possibly have coding errors are found out by retrieving and are again examined and checked to ensure the correctness of the coding.

1.2.6 Countermeasures implementation and review. After the countermeasures are established, the implementation of each countermeasure is checked and executed by an assigned circle member. Th e circle member in charge of checking summarizes the prob-lems found in the countermeasure implementing process and the countermeasure eff ectiveness according to the PDCA cyclic principle, all circle members analyze and discuss the problems found in the checking process, fi nd out the shortcoming in the countermeasure implementing scheme and regu-late the shortcoming timely, so that the eff ectiveness of each countermeasure is fully displayed.

2. Results

2.1 Tangible results. Total 713 of 14,276 medical records of discharged inpatients from November to December 2012 are randomly sampled and checked, accounting for 5%, wherein 58 medical records have ICD coding errors, and the error rate is 8.13%. Target qualifi cation rate � (value after improvement � value before improvement)/(target value � value before

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Quality control in ICD coding of medical records 441

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improvement) � 100% � (8.13% � 24.57%)/(11.6% �24.57%) ∗ 100% � 126.70% , which reaches and exceeds the expected target. Progress rate � (value before improvement � value after improvement)/value before improvement � 100% � (24.57% � 8.13%)/24.57% �100% � 66.90% . Th rough inspection, X 2 � 70.161, P is less than 0.001, the improvement eff ect is remarkable.

2.2 Intangible results. Th rough this QCC activity, the professional knowledge of the members in the circle activity, communication skills, team spirit, QCC skill application, work activity confi dence, sense of respon-sibility and sense of honor are signifi cantly improved (as shown in Table 1). Th e QCC activity off ers the oppor-tunities of self expression and self-value realization to all members of the circle. In the activity, they work together to exploit the team advantages, the cohesive force among the departments is signifi cantly strengthened and an ideal working environment is initially created.

2.3 Process standardization. Four counter mea-sures confi rmed in the QCC activity are proved through practices to have eff ects on reduction of ICD coding errors, so the operation process of these four counter-measures is standardized and becomes the standard operation specifi cation in daily work and facilitates in consolidation of results of the QCC activity, the similar errors are reduced and the work effi ciency is improved.

2.4 Review and improvement directions. Because the QCC activity is fi rstly conducted, members in the circle are unskilled in the skill application in the early period of the QCC activity and are limited in the thought of analyzing problems, therefore, the developed countermeasures are few, and many problems cannot be eff ectively addressed. Th e unresolved problems can be solved by fi nding solutions in the future QCC activity in a more extensive form through further widening of thought of activity to acquire better improvement eff ects.

3. Discussion

Th e activity is conducted following ten steps (theme selection, plan formulation, status grasping, goal setting, goal analysis, strategy formulation, strategy implemen-tation and review, result confi rmation, standardization, review and improvement direction) of the QCC activ-ity. Practices show that after the QCC activity is intro-duced to the medical record management, the eff ect of reducing ICD-coding error rate of the medical records is remarkable. All members in the circle participate in the activities, create together, study industriously, exchange mutually, and help each other, create a pleasant atmosphere in the workplace, the activity also creates more learning and training opportunities for medical-record-management staff [5]. Th e members in the circle can be better aware of the importance and duty of their work, and thus are more proud of their work, the co-operative spirit with the same objectives is established, and the continuous improvement of the medical-record-management work quality is facilitated.

References Lin Ruirong . Quality Control, 1st edition . Xiamen: Xiamen [1] University Publishing House , 2000 : 146 . Huang Pengcheng , Zhang Xin . Necessity for Continuous [2] Improvement of Medical Record Quality . Chinese Medical Record , 2012 , 13(2) : 15 – 16 . Li Chunlan , Chen Xinlai . Cause analysis on 5,000 Cases of [3] Medical Record Encoding Errors . Chinese Medical Record , 2011 , 12(9) : 23 – 24 . Qin Anjing , Wang Wenda , Da Hanling . Cause Analysis on Disease [4] and Surgical Encoding Errors from 21 Hospitals in Beijing . Chinese Medical Record , 2008 , 9(7) : 4 – 6 . Zhao Rong , Gao Qian . Improvement of Comprehensive Quality [5] of Medical Record Administrator . Chinese Medical Record , 2012 , 13(6) : 12 – 13 .

Table 1. Comparison of intangible results before and after QCC activity.

Before improvement After improvement

Items Total score Average score Total score Average score Activity development Positive/negative direction

QCC skill application 30 3 41 4.1 1.1 ↑ Team spirit 30 3 47 4.7 1.7 ↑ Professional knowledge 31 3.1 41 4.1 1 ↑ Communication and coordination 30 3 40 4 1 ↑ Activity confi dence 30 3 45 4.5 1.5 ↑ Responsibility and honor 30 3 47 4.7 1.7 ↑

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