Medical records at Anersley Hospital (This case was prepared by J.R. K Berridge and P. R. Tebbit University of Aston Management Centre) Anersley Hospital is a long-stay psychiatric and geriatric hospital of some 800 beds. It sprawls across an extensive site in a suburb of a large town; its many piecemeal additions over the past seventy years have no architectural distinction. Many of them are wood and metal huts and buildings erected during the 1939-45 war. During the last three years the hospital has become a centre for psychiatric treatment in the town and surrounding region, as a small peripheral hospital and wards are closed down in a rationalization programme. The number or beds in the hospital has declined as more patients are treated on an outpatient basis, and the concept of community care spreads. But outpatient clinics conversely have become a much more major part of Anersley Hospital’s activities, and new facilities have been built to cater for the greatly increased number or outpatients. The rather unplanned and erratic nature of Anersley Hospital’s expansion was reflected in the haphazard siting of facilities and departments. Perhaps the Medical Records Filing Department was one of the worst examples of this. It was at the end of a long corridor on the extremity of the hospital buildings, right away from clinics, appointment clerks, or the rest of the Medical Records work. It was accommodated in a large wooden hut - one of a series leading off this corridor, and now mainly used as stores. The hut was dilapidated on the outside, but inside it had been made cheerful by the colourful posters and cartoons that the staff had pinned on the walls, and other touches of homeliness and individuality. An example of this was the hand-painted sign on the door above the official 'Medical Records Filing Department'. It limply read 'The Shack'. The desks and equipment in the Filing Department were equally worn and out of date, and the actual filing racks were a home-made selection of miscellaneous designs of varying ages that had just accumulated over the years. The physical layout is shown in Figure 6.1. Working methods had also apparently evolved over time, and there were no procedures or systems. Patient records were collected and returned quite informally by a variety of staff, nurses, clerks, orderlies and porters; the only, security seemed to be whether they were known to the staff of the filing department. Sometimes clerks or porters who came regularly for records and knew the methods of filing would ask permission to help themselves to records if the filing clerks were particularly busy. Appointment clerks from the outpatient clinics would often come down casually to the filing department some two or three days before a clinic and jointly with the filing clerk search out the records needed, having a pleasant chat at the time. Conversely, it was not unknown for a filing clerk to make a private arrangement with an appointments clerk to assist with the running of a clinic if things were busy at that end of the hospital. The surprising thing to a stranger was that the filing department worked markedly well. The success rate in finding records was very high, even those old, odd elusive ones. The degree of co-operation with consultant and nursing staff was high - there was never any quibbling about demands for records at awkward times, or at the last minute when extra patients attended a clinic. Undoubtedly the filing department worked on good memories and easy personal relationships, but it did work!

Figure 6.1

Mrs Price is senior medical record clerk. She has been employed in the medical records at the hospital for nearly thirty years, and has been in charge of the filing section for about eight years. Everybody in the hospital seems to know her, and she is liked for her equable temperament and pleasant disposition. Four female medical records clerks report to her, and she in turn reported to the Hospital Secretary under the previous structure although this was changed about a year ago. Although Mrs. Price was nominally in charge of the filing department, in practice, she and her four assistants all did the same work, allocating it amongst themselves in approximately equal proportions by mutual agreement. There never seemed to be any problem of keeping up with the constant stream of filing and requests, even with the added volume of work due to the new outpatient clinics. In a busy period, people would work through tea-breaks, and in slack spells they would liaise (that is, gossip) with their counterparts in other departments. At teatime, mornings and afternoons, one of the clerks would slip out down the road to a local bakery and bring cream doughnuts for all the staff plus any visitors who happened to be there. Not surprisingly, visitors were frequent happenings! The doughnuts were financed

through a peculiar custom. In the corner of the working space was a large waste-paper basket, into which clerks would throw crumpled balls of scrap paper from their desks; if they missed the waste-paper basket, they had to pay a “Fine” of one penny into the doughnut fund. Other clerical workers in the hospital regarded the filing clerks with some envy as having a nice job, and if occasionally any vacancies occurred there was never any problem filling the post by internal transfer. About a year ago, with the decision to centralize many of the psychiatric and geriatric outpatient clinics for the conurbation served by Anersley Hospital, and with the drive to reduce the number of in-patient beds, a greatly increased load of outpatient work built up. To cope with the new demands, new clinic buildings were provided, new equipment purchased, and new staff appointed. Medical records work was included in the reorganisation. A spare pavilion was found (vacated by long-stay patients) and the two wards were expensively converted into an extra outpatient clinic facility with an integrated medical records department. The physical layout is shown in Figure 6.2. All the planning and design work was done at Regional Board level, with the liaison of the secretary in the Anersley Hospital at local level. The pavilion was completely rebuilt, tastefully decorated, carpeted, air-conditioned and equipped with the latest furniture, office equipment and filing racks.

An organisation and methods study had confirmed the obvious inefficiencies of the old scattered medical records department. Medical records had been at one end of the hospital, and outpatient clinics and appointment clerks (effectively under the control of departmental sisters) at the other end. The medical secretaries had been located in several small offices around the hospital (for instance in small rooms attached to the wards where they could be at close hand for doctors) and frequently were unoccupied, due to lack of work in their sections. All three (records, appointments, and secretarial) were thus gathered together for reasons of economy and convenience in obtaining and processing documents. Just before all these alterations were completed, a group medical records officer was appointed to be in charge of the integrated department, and to supervise the changeover and start-up of the new system. The appointee was Mr. Fraser. He is in his 40s and is an alert individual who is well informed about the technicalities of his job. He is keen to improve the medical records service. He earned a good reputation in his previous job as records officer in a smaller hospital. Mr Fraser very quickly worked out master plans for the detailed operation of the new department, and for the transfer of equipment, records and personnel to the new office. He spent a considerable amount of time liaising with the regional design and organization and methods team so that he appreciated the finer points of their designs and recommendations and could use the equipment to the full. Then he converted this information into working instructions for the staff to follow in advance so that everyone should know her task as soon as she moved over. The actual movement of the records was his masterpiece of planning, and quite painless for the other staff – to such an extent that the Group secretary congratulated Mr. Fraser on the continuation of the records service with scarcely any disruption. Friday clinics were cancelled that week; the records staff cleared up all outstanding documents on Friday morning – and then were given Friday afternoon off as holiday. At 1.00pm a veritable army of

porters and helpers descended on the records office. With the hospital secretary and Mr. Fraser in charge following the master plan, every document was removed right across the hospital and correctly refilled by 4.00pm on Sunday afternoon. At 8.00am on Monday morning medical records filing department started up again as if nothing had ever changed. The remova l team knew the new locations and routines from the working instructions that Mr. Fraser had issued, and he was on hand all the time to issue supplementary instructions over any problems. Figure 6.2

Working methods were very different in the new department, but Mr. Fraser had taken the trouble before the move to get people trained in advance through a series of instruction meetings which he conducted with every member of the filing staff. Here are some changes. So that a real measure of security could be retained over records, a floor-to-ceiling glass screen had been erected at the end of the records department. All the filing clerks had desks behind the screen, and behind them were the sliding filing racks, shiny and new. The only entrance to the filing area was through one door next to Mrs. Price’s desk – and she had precise orders from Mr. Fraser to admit only persons holding senior administrative positions in the hospital and whose names were on a list which he had provided for her. Reciprocally, it was laid down that the filing clerks were allowed to leave only at designated times, unless in exceptional circumstances. Anyone wanting records had to bring an authorization to a sliding window beside Mrs Price’s desk, hand the request over to her, and she would allocate it to one of the clerks. In practice, almost all requests were brought by the medical records messenger, a man who had been appointed when the new department was opened for duties of receiving demands from wards and departments, transmitting them to Mrs Price, subsequently collecting them from her and taking them to the ward or

department. Several of the filing clerks questioned the reason for this procedure when Mr. Fraser was instructing each of them at pre-move training sessions. He explained the need for professional standards of security with records – citing the unfortunate case that had befallen him some years earlier when a drunken porter had recited some rather explicit case notes to an enthralled audience in the “spit and sawdust” bar of a local pub! In many other ways, the new methods introduced by Mr. Fraser began (as he said) to “get a grip” on the filing section. Gone were the piles of unfiled records that occasionally used to lie on desks overnight in times of rush – all work had to be cleared each evening. The use of tracer cards was made mandatory whenever records were removed, even for use within the medical records section. The master index was no longer treated in the “cavalier fashion” (Mr. Fraser’s expression for everyone working on it) that had prevailed - Mrs. Price alone was allowed to touch this, and all requests had to be made by the filing clerks to her. An attempt to paste cartoons and pictures onto the glass screen was quickly checked by Mr. Fraser (it was unsightly), and tea-break now consisted of a proper quarter hour in the staff dining room where coffee and biscuits were provided for a small weekly sum. Mrs. Price was instructed by Mr. Fraser how to keep a tally of the amount of work passing through the section (using controls devised by the O & M team) and to ensure that every clerk was doing her fair share of the volume of work each day. At the same time, Mr. Fraser kept a supervisory eye on the proceedings, and felt it his duty to squash some rather irresponsible behaviour involving trying to throw paper balls through the sliding glass door while it was open. In all (as he informed the hospital Secretary, Mr, Littlewood) he was instilling professional pride and values in the filing supervisory position and skills by always ensuring that changes and instructions were made to her as his “requests”, to be passed on as instructions to the clerks. During the six months that followed the move, the service provided by the medical records filing department began to run into difficulties. Records were obtainable far less reliably than previously – there were often delays, and the sudden requests at the last minute were often the subject of argument. Filing of records began to get behind, and so Mr. Fraser instituted a ruling that any records unfiled at the end of the day should be returned to Mrs. Price for safekeeping; the stock of such records grew alarmingly. Mrs Price attempted to file them herself the following day (in addition to her normal work) but never seemed to catch up. It became understood that once records had been passed over to Mrs. Price, they ceased to be the responsibility of the clerk who had originally been assigned the task of filing them. The same sort of problems were experienced with the master index, as a pile of master index cards awaiting replacement grew higher on Mrs. Price’s desk. Mrs Price requested Mr. Fraser to let her staff do an hour’s overtime each evening for a week to clear the back-log, but Mr. Fraser refused with the words “If the clerks spent less time chatting, and got on with the job they’re paid to do, there’d be no problem – the O & M team didn’t recommend any overtime”. Although the clerks mentioned this solution to her, Mrs. Price never tried to raise the subject again with him. Due to inefficiencies caused by misplaced or missing records, the work was made slower, and the back- log became larger than ever. In an attempt to speed up the pace of work, the clerks began to omit the tracer card when records were removed (since they had managed alright without them before). When he discovered this practice was going on, Mr Fraser used to have

periodic surveys to check up; the arguments were bitter when he (inevitably) discovered missing cards, and the clerks used to refer to him as the “bloodhound”. Clearly, Mr. Fraser did this because he was under pressure from nursing and medical staff, as well as departments, who complained to him about deteriorating service and incomplete records. Some complaints reached Mr. Littlewood, but being busy and also believing in delegation, he felt he should allow Mr. Fraser to have a full opportunity to sort out initial difficulties in the system without the interference from above. After all, he was the group medical records officer.; The matter came to a head when, one evening at about 11.30pm, Mr. Littlewood was called from bed to the telephone by an icily-polite consultant who wished to inform him that he had been waiting for exactly three hours for the records of a patient who had just been admitted under a section of the Mental Health Act 1959. It was known that the man had been both an inpatient and an outpatient of the hospital before, but three hours’ search by the night telephonist/records clerk had failed to reveal any reference or notes at all. Mr. Littlewood rang Mr. Fraser and tersely asked him to meet him at the hospital as soon as possible. It took Mr. Fraser about twenty-five minutes to find the patient’s records; they were in four different places, three wrongly filed and one unfiled. Mr. Littlewood searched also, and was dismayed with what he found. There were piles of notes stuffed into clerks’ desk drawers, bundles of reports from departments weeks old lying in boxes in the innermost racks, there were missing incomplete tracer cards, the master card index appeared very deficient, and beside Mrs. Price’s desk was a new addition – a smallish wooden rack from the “shack” with three shelves for “pending” (all full), and one for “unaccountable” (part- full). As Mr. Littlewood searched, the consultant stood beside him, and related a series of carefully-documented and heart- felt incidents about the shortcomings and failures of the new medical records filing section. The consultant departed to the ward, bearing the records. Mr. Littlewood regarded Mr. Fraser sourly, “We will meet at nine o’clock today in my office to find out why this has occurred, and what we are going to do about it. Goodnight”.