I read with interest Dr Rangachari's article, The Strategic Management of Organizational Knowledge Related to Hospital Quality Measurement and Reporting, on the relationship of organizational knowledge-sharing structures and leadership characteristics to coding accuracy of medical records used for quality measurement.

I agree with his findings that knowledge exchange network structures that are rich in brokerage (or structural holes) and hierarchy are more effective to adapting to change and improving quality measurement. These organizations have proactive senior leadership. There is better coordination between subgroups with regard to knowledge exchange given that each group has a different focus and level of understanding of quality measurement. There is also a necessary connection to the changing external environment, which enables the organization to align professional values with the values of the community.

I would like to note that I found a few missing components in the study. The study did not highlight the importance of clarifying the roles of the various staff involved with regard to quality measurement and improvement. Given the brokerage nature of the structure, it is even more important to have clear roles and ensure that these roles are aligned within and between subgroups. Although the study mentioned the importance of aligning organizational priorities, it did not address the degree of centralization with regard to decision making. I think this is terribly important because of the structured holes that would exist. Who sets policy and priorities, who initiates activities, and who grants final approval must be well understood. This could be incorporated into the role definitions.

I would also like to suggest that the study did not deal with an element that I consider critical to the recommended strategies. The study did not specifically identify the establishment of efficient and effective processes and controls. An organization can hire quality staff, establish formal authority, ensure good communication, analyze the outcomes, and ensure senior leadership involvement, but I believe it must have clearly identified the process steps with appropriate controls to actually improve documentation and coding.

I would have liked to have seen some consideration given to process innovation. Why could doctors not input the instructions onto an electronic tablet that is automatically synchronized with the hospital database? If the doctors do not supply the correct data, the system could immediately advise them of a possible discrepancy with warnings of an override if selected. There would be no errors of interpretation of translation between doctors and orders. In Australia, several ambulance services now use electronic patient care records, and in the future, these records ill be loaded electronically into the databases of hospitals. Also, the ambulance services are standardizing their databases, which will allow for quality measurement and analysis on a nationwide basis. There is enormous opportunity for process innovation to support quality measurement and reporting going forward. I would like to see more research in this area.

Theresa Smith

Executive Business Manager Operations-Metropolitan Region Ambulance Victoria 375 Manningham Rd Doncaster, Victoria 3108 Australia.

REFERENCE