2/15/2012 – As

By Lee M. Duke II, Chief Physician Executive

many of you know, Lancaster General Hospital underwent its 2-year State Department of Health inspection.  While the inspection results were overwhelmingly positive, there were opportunities for improvement across the system.

One area, "Delinquent Chart Completion," directly affects the Medical and Dental Staff. The Department of Health identified over 300 records which were not completed in the prescribed 30-day period. While the vast majority of physicians do complete their charts within this period, a small number of physicians have frequently violated this statute. Occasionally, physicians have continued to practice while on suspension, which is a violation of our internal Bylaws.

In response to the deficiencies, an action plan will be established by the Medical Staff leadership and Medical Records Department. This will include educating the Staff, utilizing the Medical Executive Committee as a reporting committee for violations. Proposed changes include shortening the time period for chart completion to 21 days. 

In addition, the Department of Health cited the Hospital for inconsistently obtaining proper restraint orders.  This is an area of focus for The Joint Commission and a team was already addressing this issue.  Standardized order sets for violent and non-violent restraint will have to be used more consistently.  There must also be improved compliance with physician re-evaluation and reorder with restraint use.  An education plan, revamped order set, and chart review for compliance are part of the Action Plan.