It might be easier than you think to get that difficult dictator to shape up.

By Lynn Jusinski

One of the physicians Donna Brosmer, CMT, FAAMT, NREMT-B, transcribed for in the past dictated numerous reports from the bathtub—water running, splashes, echoes and all. Many MTs are privy to all of the sounds that go along with eating—dictators sucking on straws, chewing on food and gulping down drinks. And MTs have also grown unhappily accustomed to the classic dead air, when the physician gets distracted and forgets to push that critical "pause" button. Of course, there are also the fabled stories floating around the MT world of the dictator who just had to dictate his reports from the comfort of his convertible, top down, wind blowing, cars racing by.

These practices don't bode well for patient care, and bad dictation causes headaches to MTs, medical transcription service organizations (MTSOs) and HIM directors as well. Rather than just plugging along as the dictation gets worse, speak up—as an MT, an MTSO or an HIM director—and make the offending dictator aware of the problem. Tools exist to help your case, and a little effort may be all it takes to get that dictator off the path of inaccuracy and inefficiency and on the road to good dictation—convertible optional.

Make it Personal

In the course of their packed schedules and long hours, many dictators may forget about the person on the receiving end of the dictation file. That's easy to understand, according to Brenda Hurley, CMT, FAAMT, director of industry relations and compliance with Medware, Maitland, FL. In the past, most MTs worked onsite in hospitals or clinics. If the facility was small enough, chances were that the MT and the dictator knew each other. Hurley recalled working as a transcription supervisor at a smaller hospital. "We could go tap dictators on the shoulder in the chart completion room," Hurley said. "I'd tell them that they needed to speak up, little things, just pinpointing. Then, maybe the next time, I'd ask the physician to slow down a little during dictation."

Things changed. Now, many facilities outsource medical transcription, and often, MTs work from home. Those little problems, like a dictator who speaks too softly or one who races through dictation, don't come with as easy a remedy as a simple tap on the shoulder and a friendly conversation. "It is so easy to forget that there's somebody there trying diligently to decipher what is being said," Hurley noted.

Sometimes, all it takes is a friendly reminder. Brosmer, quality officer with Spheris, Franklin, TN, goes into facilities and speaks directly to dictators about good dictation practices. When a client approached Spheris about improving dictation practices and asked if someone could come in to speak to the dictators, the company put together a presentation last year and took it on the road. The PowerPoint is full of little tips to help remind dictators that MTs are out there, and that little things, like not yawning when dictating, can make a big difference.

The presentations appear to be working, Brosmer said. One particularly bad dictator showed up to one, and afterward he came up and thanked the speakers for the presentation. "This peaked our interest and we were very impressed to see major improvements in his dictations," Brosmer noted.

Don't be intimidated to go in and speak with physicians, she advised. Instead, approach dictation practices from a team standpoint—everyone wants what's best for the patient. "If you can approach it from that common goal, everybody wins—the physician, the MT, the company and the patient," Brosmer said.

Keep It Simple

If you're dealing with dictation that's not up to snuff, a number of options exist. If you're an MT, let a manager know about a troublesome dictator. If you're in management with an MTSO, and you notice a pattern with a particular dictator, it might be time to go to your contact—in hospitals, typically the HIM director—at the facility. If you're an HIM director and your MTSO approaches you about a problem dictator, you could hold a refresher session on dictation practices or address the dictator in person. Dictators are usually very busy people, and they simply may not realize how big of an impact little things may have on dictation.

If you decide to deal directly with the dictators, use simple reminders. Brosmer found that telling dictators to speak as if they were speaking to a patient in an exam room made an impression. "Sometimes they don't think of if that way," Brosmer explained. "That helps them realize, OK, I need to slow down and not speak 90 miles a minute, or not be whispering—that they need to do this at a conversational pace."

Corralling busy dictators in for a full-scale presentation may not be the easiest thing (Brosmer suggested providing food), and there are other ways to try to improve dictation practices. Hurley, who helped assemble the Dictation Best Practices Toolkit, had heard of MTSO staff members going to clients' facilities and letting risk managers there listen to some real dictation from that facility. "The risk manager was, needless to say, appalled and amazed all at the same time—amazed that anyone would think anyone could decipher it, and appalled that it was pretty indecipherable," Hurley said. "They arranged a time at a staff meeting to play snippets of this dictation. There was an excellent message that was brought there."

If this seems like a stretch, there are still other options. Medware provides clients with information on best dictation practices, and on new client start-ups, basic dictation instructions are provided. Opti-Script, State College, PA, takes a similar approach, and gives HIM directors a copy of the Dictation Best Practices Toolkit CD. If a problem arises with a dictator, Sharon Allred, CMT, FAAMT, vice president of operations and chief operating officer with Opti-Script, goes back to that HIM director and addresses the problem. "I usually don't tell them about specific dictators when I first give them the CD," Allred said. "But it then establishes the relationship, and I can then do that intermittently as problems are identified."

Allred recalled another method for getting dictators to shape up. She has a hospital background, and in her former hospital job she handed out small laminated cards, about the size of a credit card, that had all of the headings listed for the dictators to reference. Small steps like this can help keep dictators organized as they go through reports.

Make the Connections

Whether you're an HIM manager or service planning to address dictation practices in a presentation or one-on-one, always keep in mind why dictation practices matter—and don't keep those reasons a secret. With her hospital background, Allred knows some of the buzzwords that can garner an HIM director's attention and may motivate the HIM director to help dictators become more compliant. Risk management is the biggest one, Allred explained. "No hospital really wants to be sued or have something adverse happen to a patient because of errors in dictation," she said. "The other thing is turnaround time (TAT). All HIM managers are working with tight TATs, and those are getting shorter, not longer."

Hurley brought up a few more key arguments when it comes to making a point about good dictation practices, whether directly to the dictator or to the HIM director at a facility. Any time you have more than one person listen to a voice to fill in blanks, that costs extra money to generate that report, Hurley noted. More levels of review, of course, will also lengthen TAT. With a longer TAT, patient care can also be impacted, as the continuous communication may be broken, and critical information may not be available so that clinical decisions can be made. All slowdowns will affect the billing process and the revenue cycle, and a simple thing like dictating in a quiet place can make all the difference.

A few simple reminders might help a dictator realize the importance of good dictation practices, and may take away a lot of headaches from MTs, MTSOs and HIM directors. Sometimes, it's as simple as reminding dictators that there is a person on the other end of the line, or giving dictators a simple peek into the world of an MT, who has to deal with the noise in the background or the unappetizing sounds of the dictator chewing on a burger. Rather than sitting by and possibly compromising patient care, try to make a difference in dictation practices. "Until we get everyone to the table and everybody shares what their experiences are, nobody understands what the other person is going through—physician and MT," Brosmer said. n

Resource

Dictation Best Practices Toolkit. www.ahdionline.org/scriptcontent/DBP.cfm Accessed April 28, 2008.

Lynn Jusinski is an associate editor with ADVANCE.