Finding a common language: A key component of quality improvement

Nov. 28, 2018 / By L. Gordon Moore, MD

I think it’s reasonable to say that most people working in health care are motivated to deliver high quality care to the people they serve. Because humans are complicated organisms, knowing the right treatment or intervention for a particular person is not always clear. The scientific method of systematic observation, measurement and experiment helps us get closer to truth and understanding. 

Systematic observation, measurement and experiment rely on standard language—the degree to which the words we use have the same meaning. Health care is rich with specific language that clinicians use to avoid ambiguity. Ambiguity in communication increases the possibility of harm.

In a conversation with Dr. Geoffrey Rose and Heather Joyner, they describe Atrium Health’s work to reduce ambiguity and improve the standardization of language in a person’s medical record. Ms. Joyner discusses the work of coders and clinical documentation improvement nurses as they identify ambiguity in charts and query clinicians. Dr. Rose describes the connection between this work and Atrium’s quality improvement programs.

The improvement in their initial work led to increasing the number of diagnoses and scaling this work across their health system. They have improved quality scores and, due to their clinical standardization, have been able to reduce the number of claims rejected by insurers.

Their discussion is a good example of a quality improvement program that uses technology to reduce the work burden while having a beneficial effect on their health system’s bottom line.

L. Gordon Moore, MD, is Senior Medical Director, Clinical Strategy and Value-based Care for 3M Health Information Systems.