By Andy Norton, MD, CMO and regional VPMAs Jim Gengaro, DO and Jon Stallkamp, MD
- Main Line Health (MLH) has been cited by The Pennsylvania Department of Health and CMS for not assuring completion of medical record documentation by 30 days post inpatient discharge.
- MLH suspended its Administrative Suspension practice during the Epic installation and must re-institute it now.
- Medical Record deficiencies are routed daily through the Epic In-Basket. Regular review of the Epic-In-Basket should prevent any deficiencies.
- The Medical Records Committee has recommended to the Medical Executive Committee (MEC) the following modifications in the delinquency process:
- Medical Record will be considered delinquent on Day 21 and suspension notifications would be sent by the MLH Medical Staff Office to the medical staff member via email and office fax
- The Administrative Suspension date would be included in this notification
- Suspensions will commence 10 days from the notification date
- With Administrative Suspension the medical staff member cannot provide clinical care within the MLH inpatient and hospital-based procedural environments; in addition, no new admissions, surgeries or procedures can be scheduled
- Administrative Suspension would be removed on the first business day after all delinquencies are completed.
Last March we suspended the historical medical record delinquency Administrative Suspension process during the Epic transition. We had decided not to reinstitute the process temporarily, in part due to changes in medical record management in an Epic environment. During a CMS validation survey by The Department of Health at Paoli we were cited for medical records delinquent beyond the required 30 days. We need to act now to prevent medical record delinquencies.
Considering the new Epic environment, the System Medical Records Committee has recommended to the MEC a revised medical record delinquency process. The details of the proposed changes to the Medical Staff Rules and Regulations are at the end of this memo.
The recommended new process is as follows:
- Medical Record delinquencies are posted daily in the Epic Daily Reminders and in the Epic In-Basket
- Medical records are considered delinquent at day 21
- Medical Staff are notified via email and office fax on day 21 in addition to the daily reminders in Epic
- In the written notification from the MLH Medical Staff Office the medical staff member is given the date when the Administrative Suspension will be applied; 10 days from the date of notification to allow the medical staff member to rectify the situation and to meet our required 30 day deadline
- At the time that the Administrative Suspension is in force the medical staff member cannot provide any clinical are within MLH inpatient and hospital-based procedural environments; in addition, no additional admissions, no new admissions, surgeries or procedures can be scheduled
- At all times, medical staff will have access to Epic to complete their medical records deficiencies
- Administrative Suspension will be removed on the first business day after all delinquencies are completed. The MLH Medical Staff Office will notify the medical staff member by email and office fax
- Repetitive administrative suspensions for medical records delinquencies would be referred to the MEC for further disciplinary action.
The System Chair and Chiefs along with the regional VPMAs will receive notification of medical staff in the department/division/campus approaching a delinquent status. They will be notifying individual medical staff directly by phone/text/email in addition to the notifications in the Epic In-Basket and from the Medical Staff Office.
These new modifications will be recommended to the MEC on Monday, May 20, 2019. If you have any comments or recommendations, please provide them to the Medical Staff Office, your System Chair or Chief, VPMA, Medical Staff President and/or the CMO.
Proposed changes to the MLH Medical Staff Rules and Regulations:
Section V: Health Information Management (HIM) – formerly Medical Records
- Delinquent and Incomplete Charts
- All chart deficiencies must be completed within 30 days of discharge per the Pennsylvania Department of Health and CMS Those that remain incomplete more than 21 30 days after discharge shall be considered delinquent and the physician shall be subject to Administrative Suspension process as outlined in Section XV of these Medical Staff Rules and Regulations.
Section XV: Administrative Suspension
- The administrative department responsible for the administration of the MLH policy with which the member is not in compliance (e.g., infection control or health information management) will notify the Medical Staff Office.
- The Medical Staff Office will notify the System Department Chair of the member’s non-compliance to initiate collegial intervention. If the System Department Chair cannot resolve the issue by collegial intervention, the System Department Chair will refer the matter back to the Medical Staff Office to initiate action in the form of an administrative suspension. An administrative suspension is not the result of a professional review action and is not reportable to the National Practitioner Data Bank. Remediation by collegial intervention shall not be available for medical record delinquencies which shall be referred directly to the Medical Staff Office to initiate administrative suspension.
- The Medical Staff Office will notify the VPMA at the hospital(s) where the staff member has privileges that the member is non-compliant. The VPMA, or the CMO in the absence of the VPMA, shall place the non-complaint member on administrative suspension and notify him or her through the Medical Staff Office that their clinical privileges have been or will be administratively suspended. The duration of the suspension may be time limited or may be imposed for an indefinite period until the basis for the imposition of suspension is remediated. The Medical Staff Office will:
Notify the medical staff member by email and fax;
- Notify IT security to move the member’s Epic to view only access; and
- Notify by email Administration, Quality, OR, Cath Lab, Chiefs & Chairs, Hospital Presidents, and Nursing Administration that the staff member is on administrative suspension and has automatically relinquished his or her clinical privileges for a defined period or until further notice.
- While a staff member is on administrative suspension, he or she may not care for patients admitted to a Main Line Health hospital or admit new patients to a Main Line Health hospital. Patients already in house will be cared for by another staff member of the affected staff member’s group practice, or the member’s coverage group. All surgeries and procedures for the affected staff member during the suspension will be cancelled by the affected department. Additional surgeries and procedures may be scheduled for the period outside of the suspension if the suspension is time limited.
- Emergency procedures may be permitted at the discretion of the VPMA, or the CMO in the absence of the VPMA.
- The responsible administrative department (e.g., infection control or health information management) will notify the Medical Staff Office once the staff member is in compliance with the MLH policy or has obtained an approved exception.
- The Medical Staff Office will notify the VPMA at the hospital(s) where the staff member has privileges that the member is compliant. The VPMA, or the CMO in the absence of the VPMA, shall remove the staff member from administrative suspension and notify him or her through the Medical Staff Office that their clinical privileges have been restored. The Medical Staff Office will:
- Notify the medical staff member by email and fax
- Notify IT security to move EPIC access back to the previous level
c. Notify by email Administration, Quality, OR, Cath Lab, Chiefs and Chairs, Hospital Presidents, and Nursing Administration that the staff member is no longer on administrative suspension