Verbal and Telephone Order Compliance SBAR

Posted on Sep 5, 2018 in Health Information Management | 0 comments

Situation:  In Q2 of 2018, Sutter Delta compliance for CMS Verbal and Telephone order was at 81%. In June, the order compliance was at 82%. According to TJC/CMS/Title 22, the requirement is that verbal orders are authenticated within 48 hours.  (ABSMC is at 83% compliance over the last 12 months.  We have not been able to move compliance in the right direction.)

TJC/CMS/Title 22


·          Verbal orders are authenticated within the timeframe specified by law and regulation. Note 1: For hospitals that use Joint Commission accreditation for deemed status purposes: If there is no state law that designates a specific time frame for authentication of verbal orders, the verbal orders are authenticated within 48 hours

·          JCAHO RC 02.03. 07

·          CMS 482.24 (c) (iv)

·          Title 22 70263


Background:  In May, Sutter Delta has CMS Survey. Sutter Delta was cited for not compliant to TJC/CMS/Title 22 requirement of verbal orders signed within 48 hours. (CMS, CDPH and other regulatory agencies are making the rounds.  We are at risk for citation due to our low compliance.)

Assessment:  Questions arose regarding our physicians are aware of requirement on CMS Verbal and Telephone order. What tools and support we can provide to our physician to get orders signed within 48 hours.  (Currently, we have a unsigned VO/TO within 48 hours report that can be run daily.  The report has been sent out a few times a week to select providers since Delta was cited and when regulatory agencies are in the house)  The Delta Lean consultant is also compiling a daily graphs to track progress.  This is something we can look at implementing at ABSMC as well.  Examples of tracking tools attached.

Recommendation:  Sutter Delta created a team, which had CME, Dept. Chairs, physician liaison, Lean consultant and HIM lead to educate our physician on requirement of verbal orders signed within 48 hours. Initially, meetings were held daily and then moved to weekly.  The Physician liaison took the lead to call or text all the physician who were coming close of 48 hours of signage and explain the importance of order been signed within 48 hours. Medical Staff informed all physician regarding notifying HIM dept. when physician are going on vacation, so HIM can put chart on hold to prevent deficiencies aging. The compliance rate improved by 9% since June. We are currently at 91% compliance and our goal is to get to 95%.  (ABSMC created a VO workgroup 2 years ago and we have performed a lot of education to date through Medical Staff but it has not been enough to move us closer to our goal.   I recommend we look at expanding our workgroup to include our CMO, Medical Staff Department Chairs, Physician Liaison, Medical Staff Directors, Lean Consultant and Clinical Operations Team)


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