Overview

All services that are provided by the organization are evaluated at least quarterly via a systematic review of the clinical/medical records (charts). The purposes of the review are to improve the quality of services provided to each client, assess appropriateness and patterns of utilization of services, and identify training needs.

Accreditation Requirement(s)

• Documentation that the quarterly records review was conducted of at least a representative sample of open and closed records.
  
• The review should be performed by qualified and trained personnel (usually quality improvement staff members, clinical supervisors, program managers, nursing supervisors, clinical peers, and/or outside reviewers). The reviewer cannot evaluate records for which he or she is the case manager/primary therapist.
  
• Evidence that the review includes:
  
  
  • Whether or not clients were provided with a complete orientation to services
    
  • That assessments were thorough, complete, and timely
    
  • That the goals and objectives on the treatment plans were the result of the assessments and included client input
    
  • That the services provided related to the program goals and objectives and followed the organization's policies
    
  • If the treatment plan was reviewed and updated
    
    
• The information that is collected as a result of the reviews is provided to the appropriate staff for feedback purposes and is used for continuous program improvement, including the identification of staff training needs.

Implementation Tips

Some Implementation Tips provided, in part, by Robert Johnson at: www.accreditationnow.com.

• A regular review of the clinical and/or medical records of persons served is central to improving the quality of individual programs. This practice has its roots in the medical model approach to the records maintained in health care. That model emphasizes a quantitative or technical approach to record review to ensure that forms have been signed and documents are in the appropriate place in the records. Record review for behavioral healthcare organizations has evolved toward a process review in which the degree of quality is assessed. The importance of quantitative and statistical approaches still remains but is typically done by non-clinical staff to assure legal and billing requirements are being met.
  
  
• A quality record review in a behavioral healthcare setting may involve direct care clinical staff. By involving clinical staff in the review process, direct learning occurs through the process of understanding and reviewing a set of criteria that is determined to represent quality services. Qualified staff members such as Quality Improvement Directors, Clinical Supervisors, Nursing Supervisors, Medical Directors, and Program Managers can also conduct reviews of the quality of records. Some programs utilize outside reviewers (e.g., contract quality improvement organizations or individuals). If the process is a supervisory one, then it usually becomes part of the employee's annual job performance review and may take the form of a quality assurance audit, instead of a continuous quality improvement focus.
  
  
• If the organization maintains two client records, a clinical record and a medical record—which is still true at many opioid treatment programs—then qualified staff must conduct reviews on both records.
  
  
• The usual conformance problem with this set of standards is finding that the organization has not conducted reviews of closed charts/records. Organizations just leave out the closed records from the process or sometimes state that they don't have many closed records to review. Even if the sample size is small, evaluating closed records is an excellent opportunity for determining if clinical staff are meeting the CARF standards for transition/discharge planning, particularly 3.D.3, the components of the discharge/transition plan.
  
  
• Since the standards advise that a sample of open and closed records may be reviewed, larger organizations may opt to follow this guidance. CARF does not suggest any particular sampling technique; however, it is important that the review includes records from all of CARF's identified "core programs" across the organization (e.g., opioid treatment, detoxification, residential, and outpatient). Organizations that utilize a peer review approach may tell clinicians to select a certain number of records each quarter, have the records selected by supervisors, or utilize the automated client information database to randomly select records by unique client identifier.
  
  
• This policy and procedure for Quality Records Review includes two reporting forms. One of the forms is used as the record is being reviewed (a checklist) and the other form is used to total the aggregate results. The forms are meant to be an example or overall guidelines for this process. The forms meet the basic tenets of the accreditation standards. However, they can and should be expanded to assess other important and relative clinical processes that can be reviewed through the record review process. Note: CARF's fiscal standards 2.B.3.a-c state that a quarterly review of a sample of records should occur to ensure that the services for which the organization bills accurately reflect the services that were provided, including congruence with dates of service provision and dates of billed episodes of care. Some organizations include this utilization review process in the Quality Records Review.
  
  
• If not already in place, the organization should strongly consider a initiating a Quality Review Committee within the organization or separate programs that involve clinical staff instead of having a single reviewer complete the process. It has been our experience when staff are not involved in the review and instead are receiving "reports" of areas to be corrected, it typically does not translate into the overall changes that are needed to improve services.
  
  
• Initially, clinical staff members tend to be somewhat resistant to a peer review process, as they are hesitant to "review" their peers' work. However, if presented as a learning tool for overall program improvement, the process is usually accepted and becomes a dynamic method for staff to support each other in improving their skills, knowledge, and abilities. Additionally, it is important to educate staff that the process provides aggregate information to assist management in making decisions related to the organization's staff education and training.
  
  
• It has been our experience when reviewing organizations' records to find documentation inconsistent throughout the record in many areas covered by a review process, yet the results of the review process indicate that records were reviewed and practices were deemed appropriate. This inconsistency is indicative of a poor review process that is most likely taking up staff time and energy but not producing effective information to improve practices. Again, a peer review process that is quality- and process-based rather than technically-based (quantitative checklist) is the organization's best chance of producing information that is useful, identifies opportunities for improvement, and ultimately improves the outcome of services.
  
  
• The Quality Records Review should be tied directly into the organization's information management system and should be used to improve the quality of services. Regular reporting of overall results should occur (sometimes to the organization's Quality Improvement Committee, and/or to the Training Director/Human Resources staff) and decisions made based on the results. Examples of organizational change as a result of Quality Records Review may include additional training offerings and/or allocation of funding for staff training, changes in program design and implementation, changes in personnel assignments, and evaluation of staff competencies.