4. Are the steps in the process easy to read and understand?

5. Are all the elements of a good mission statement present?

6. Are all the elements of a good vision statement present?

7. Does the presentation identify the external and internal customers of the process?

8. Does the presentation identify the customers' requirements? If so, how? If not, why not?

9. Does the presentation display the team's improvement process findings?

10. Are the team's recommendations based on the data the team collected? Are the recommendations sound? Are there other recommendations that the team did not identify?

Improving Documentation: A study of dictated discharge summaries Mission Statement Customers Hospital HIM Department is committed to providing a safe patient environment through timely and complete discharge summary documentation for patients, hospital staff, and its payers and accreditors. Internal customers: physicians who dictate discharge summaries External customers: patients, hospital staff, payers, accrediting bodies National Benchmark: Average national turn around time for dictated discharge summaries for equivalently sized hospitals for first quarter calendar year: 5% under 48 hours Customer Requirements Outcomes Accurate assignment of reports to be dictated, functioning dictation system Timely production of reports into the medical record Vision Statement To produce dictated discharge summaries for all inpatient stays according to hospital documentation standards and regulations within 48 hours post patient discharge. Survey Recommendations > Analyze/assign discharge summaries for OB charts using discharge order as opposed to discharge instructions author Team Members Please rate the following questions on a scale of 1.10.1 being the least accurate bcneficial How much do you rely on HIM letters to remind you of missing dictations to do? (10 always rely never) How do you rate the accuracy of the HIM Deficiency letter contents? (DS assigned correctly How comprehensable do you rate the information on the HIM deficiency letters? How would you rate the cash incentive program to get you to dictate sooner? Do you like having a cash incentive programs? (10-love it, 1 hate it not applicable) > Consider using penalties as well as cash Incentives; consider offering higher cash reward in relation to discharge summary dictation time. HIM Manager HIM Analysts Compliance Officer Chief of Medical Staff > Consider manipulating text on letters to clarify symbols, simplify content