Do Your Chart Audits Need Process Improvement?

chart audits process improvement

Do Your Chart Audits Need Process Improvement?

By: Jennifer Milton, BSN, MBA, CCTC

I suspect, like me, most of you working in transplant centers prior to 2006 BC,1 did not have a dedicated quality specialist—much less a team. At that time, I never would have dreamed that records would be audited so extensively for compliance, nor that I would have as many gray hairs.2

The release of the Conditions of Participation in 2007, followed by the sharp rise of shakily sent emails from your colleagues across the country bearing the dreaded message “CMS is here,3 changed your transplant life forever. Even weekends lost a little luster for those first several years, as anxiety routinely peaked every Sunday evening. ”That’s it. I’m dead. They are coming tomorrow.”

I am not sure if it was our access to countless life-saving tips & tools gathered from the transplant administrators list serve; or our attendance at remarkably insightful presentations on Medicare readiness; or just our need to reclaim Sundays4 that eventually shifted transplant centers from panic to preparedness.

The COPs had provided a framework for quality, with teeth. Compliance with the COPs was perceived to be pass/fail, and along with the use of unannounced audits and tracer methodology, the shift to preparedness gave rise to our almost universal practice of auditing all patient records to ensure we are compliant the same way, with every patient, every time.5

Centers use nurse coordinators, quality nurses, and even managers to complete these audits. This is no cheap endeavor, with salaries of $35-50 or more an hour, and up to 20 minutes per record. To complete an audit of a midsize program,6 one could spend 400 hours and over $30,000 on this isolated endeavor—man hours and dollars now unavailable for patient care or other needs.7

Given the price tag of our chart audits, we need to make sure we are spending wisely. Here are some process improvements you may want to consider for your chart audits:

  1. Shift to real-time rather than retroactive audits.

I think by now, most transplant programs have transitioned to auditing records at the time of key patient milestones such as listing, removal from the list, discharge from the transplant, or donation event. Identifying deviations in real-time not only allows you an opportunity to potentially correct issues such as missing documentation,8 but allows immediate retraining, thereby minimizing repeated errors.

  1. Move to a more ‘grassroots’ approach

Design your medical record reviews so that every nurse in your program completes them. When a milestone occurs, such as listing, have a co-worker audit the record first. If all your nurses are engaged in auditing each other’s records, their own practice and knowledge of compliance increases. As an extra bonus, when CMS arrives, they are more easily calmed when you remind them to relax… after all they each audit the same information all the time.

Swapping charts with other programs (liver audits lung, kidney audits heart, etc) strengthens your entire center. Admin support should be enlisted to audit too—timely removals from list, notifications of listing, etc. As you’ve learned in regulatory visits, there are times when your center is only as strong as your newest nurse; using a grassroots audit process ensures that even your newest nurses have a stronger track record. Your quality staff can then shift to random audits and focus on ‘auditing the auditor,’ to ensure compliance is more deeply ‘hardwired’.

  1. Don’t be afraid to retire, rotate metrics

If your scorecards demonstrate 100% compliance with two ABOs prior to listing for the last four years, it’s time to retire.9 Use your resources wisely, and pick (or don’t pick) a new indicator to monitor. Reviewing scorecards where metrics have been at 100% compliance forever diminishes the validity of the QAPI process and can dampen enthusiasm for your meetings.10

  1. Give your benchmarks a make-over

Take a hard look at your center benchmarks. Highlight any that are the same as last year, and circle the ones that were the same the year before that.11 Benchmarks should not be stagnant; move these goals so you’re always driving to get better in each little way. Also, if you have set a benchmark or goal of say, 85% for a metric that is a pass/fail regulatory requirement, make sure you are constantly moving the benchmark higher so you are driving your team to 100% as quickly as possible.

Transplant Centers generally spend more human capital on collecting data through chart audits than analyzing the data to drive process improvement. Never stop working to shift this paradigm.

Happy Auditing.


  1. Before Conditions of Participation
  2. Clairol 4RB
  3. Layman’s translation ‘H-E-L-P’
  4. Or take PTO on an actual Monday
  5. I stole than line from the great Gwen McNatt
  6. 1200 records (220 transplants + 1000 listed)
  7. Yes, you’re right, this is just a fraction of the costs of an entire quality program
  8. Our dietitians and pharmacist have grown to love these messages prior to discharge (hey, I don’t see your education note)
  9. I meant ‘Retire the metric,’ …… c’mon I’m not that mean
  10. Don’t panic, you can still spot check it once or twice a year
  11. You circled ATN didn’t you?
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