Purpose. There are many reasons to conduct chart reviews such a required by a regulatory agency, justification of billing, and research. Another frequently used purpose of a chart review is to assist in measuring quality of care. This measurement is then used to help determine if a change in process is needed to improvement patient outcomes. There are several models used in process improvement including Juran’s Universal Sequence for Quality Improvement, the Seven-step problem-solving model, FOCUS-PDCA and Six-Sigma DMAIC (Langley, Moen, Nolan, Nolan, Norman & Provost, 2009). Chart reviews can be an integral step in all of these models in gleaning data to measure the depth of the problem or if it even exists. This paper will compare the advantages and disadvantages of reviewing charts, describe the basic considerations in performing chart reviews, and describe issues that can threaten the validity of data. Lastly, this paper will look closer at the Six-Sigma DMAIC process as this is the methodology used to guide process improvement in the facility for which this information is being obtained.
Background. In 1966, Donabedian stated that the quality of health care is measured by structure, process, and outcome observation. Structure measurement includes resource quality, availability and accessibility (Donabedian, 1966). Process measurement looks at the health care services that clinicians and providers deliver (Donabedian, 1966). Outcome measurement is the end result of health care (Donabedian, 1966). Many of these measures can be obtained by reviewing different parts of a chart. For example, to ascertain if there is a proper process in place to get a patient with a ST elevated myocardial infarction from the emergency room to the cath lab in a timely fashion, one must review the charts of these patients and obtain the current time frame.
Advantages and Disadvantages. The advantages of doing chart review include that the data is relatively easy to obtain (Wong, 2009). Data obtained from chart review is also beneficial in laying the groundwork to help decide if a more involved or any project is needed (Connelly, 2008). Chart review may also unearth an opportunity that was previously unknown (Connelly, 2008). For example, doing a chart review on patients that had a Rapid Response Team called, could unearth a trend that was completely unlooked before. One disadvantage of chart review is that data gleaned from is noted to be, at times, inaccurate (Nagurney, Brown, Sane, Weiner, Wang & Chang, 2005) and incomplete (Wu & Ashton, 1997). Also, different clinicians have different charting styles and may even document in different places in the chart, which can cause misinterpretation or inability to locate needed information (Wong, 2009).
Considerations. The steps involved in performing a chart review vary due to organizational factors such as the number of people involved, the amount of data needed, the type of charting system used, and how the data will be recorded. Some data, such as demographics, is much easier to get and record than data that may need to be obtained from narrative information. If the data is complex enough, it may need a clinician with the appropriate expertise (Aaronson & Burman, 1994).
Data Accuracy. Steps must be taken to ensure validity and reliability of the data collected. Validity refers to the accuracy with which the data reflects what it is supposed to measure. Reliability is the consistency with which data is obtained. There are several steps that can be taken to ensure validity and reliability. One such step is to make certain all data abstractors are adequately trained. To, Estrabillo, Wang, & Cicutto, 2008 noted that variability can occur both when there is one abstractor or more than one. Intra-rater (one abstractor) can have variability for reasons such as fatigue, boredom, or misinterpretation while inter-rater (more than one abstractor) can have variability due to these as well as different levels of expertise and abilities to abstract data without bias. Information such as history and demographics were much more reliable than information that was time reliant such as event occurrences (Reeves, Mullard, & Wehner, 2008). . Researcher validity refers to the ability of the researcher to read the medical record and to record subject information without bias (Tobias, Nagurney, Brown, Sane, Weiner, Wang & Chang, 2005). Generally, the more people that abstract data, the higher the risk of researcher variability.
Six Sigma. Six Sigma is a process improvement methodology that attempts to decrease variation. It uses a scientific methodology to get to the root cause of variations and work at decreasing them to being 99.97% defect free Brassard, Finn, Ginn, & Ritter, 2002). Six Sigma looks for characteristics that are Critical to Quality based on the customer’s discernment of what quality is. There are six phases in a Six Sigma DMAIC model of process improvement. Defining the project is the first phase. In this step, the purpose and scope of the project is defined and background information on the process is collected. In the Measure phase, data is collected to help determine the current state of affairs. Data is collected in reference to what, when and where a situation is happening. Besides data collection, this step can use tools such as control charts, flowcharts, and Pareto charts. The next phase is the analyze phase. In this phase, root causes are identified that will be addressed in the next phase, Improve. During the Improve phase, solutions are developed, tried, and implemented. Also in this phase, the plans for implementing the solutions are developed. The improve step includes the PDCA (Plan-Do-Check-Act) cycle which assesses and improves on the solutions developed. The last phase of the Six Sigma DMAIC model is the Control phase. The Control phase is where the maintenance of processes is done. This is where training is completed and systems for monitoring the use and success of processes is done. Using this measurable method to track performance improvements allows one to stay informed as to what processes are working and what processes are not.
Summary. While there are disadvantages to using data obtained from chart review, it is an integral part of the process improvement process. It is more cost efficient and easier to obtain than prospective data collection. Safeguards must be taken to minimize variability and inaccuracies which include instruction to abstractors and using appropriate expertise to obtain more complex data. Data collection can be part of any performance improvement plan including Six Sigma. References

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