PACS Administration

You are a new manager that has just completed your department’s transition from a film system to a PACS. The majority of the staff has made the transition smoothly; however, there are several that just can’t get the new procedures and techniques correct. You also have several staff members that excel in the new environment. All of the department staff (technical and clerical) received need-to-know education from the vendor, and this education is documented. Three to four months after the transition, your PACS Administrator comes to you with a problem. One of your stellar employees, a clerk named Karen, has some unusual activity in the Audit Log and the RIS. Karen has worked in the department for ten years. She often catches other employee’s mistakes and brings them to your attention. She runs reports from the RIS that shows her completed work and her accomplishments. You have only known her for less than one year, but she presents herself as a competent employee and a leader within the clerical department. One of her main job duties is to ensure all exams are dictated in a timely fashion. If an exam is not done and wasn’t cancelled, she was to place the cancellation paperwork in the RIS to remove it from the list of pending exams. Because of the unusual activity in the Audit Log and the RIS, an audit was performed. It showed that Karen has cancelled several exams in the RIS for exams that have images in PACS. The reason she placed in the medical record for the cancellation was “No images” or “Exam not found.” The manager asked her about her cancelling exams and asked her to provide a list of exams that she cancelled from the current day. She provided two names, neither of which showed up on the audit. The manager then ran a more complete audit and discovered that Karen had cancelled those exams correctly. The manager expanded the search. Over the previous six months, Karen had cancelled several hundred exams. The other clerks, in comparison, have only cancelled 10-20 exams in the same time period. This didn’t raise a big concern, since part of her job was to cancel exams that were not done. However, over 30 exams had diagnostic quality images on PACS, which did raise a big concern. There are now over 30 exams that need an explanation. These exams were cancelled for the following reasons: “Not done” “Not found” “No images” The manager asked her about the cancelled exams and she stated that someone else must have logged on, using her password that she gave them, and cancelled the exams. The manager reminded her that sharing passwords is a violation of hospital policy. She then stated that someone must have stolen it, and was trying to blame her. The manager reset every radiology password on PACS and in the RIS to remove any excuse going forward. A memo published about protecting access to computer systems and accountability for actions. The manager then ran another audit of user activity from PACS and RIS. Exams were cancelled during Karen’s work hours at Karen’s work station. Other users had concurrent activity in other parts of the building showing that they couldn’t have cancelled the exams. The manager expanding the search by running a list of exams cancelled before the implementation of the PACS. He gave the list to a different clerk to pull all the charts/jackets on the list and placed them in his office. An inspection of the first 20 jackets revealed that exams were cancelled; however, films did actually exist. The manager then informed his superior of the investigation and preliminary concerns and continued the investigation. The majority of the exams were found exactly where they were supposed to be, in the film jacket. When asked about the exams Karen stated she was following prior management’s instructions to cancel exams if they weren’t done. She stated that the instructions included cancelling exams to avoid Medical/Medicare fraud for inappropriate billing practices. Her process was to look for exams or ask the technical staff if the exam was good enough to submit for a reading. She also blamed the radiologists, stating they told her to cancel exams that were not of diagnostic quality. None of these excuses held up to scrutiny. The audit log demonstrated that she had cancelled exams without viewing them in PACS. She cancelled exams after several other staff had viewed the exam—including the Emergency Department (ED) physicians to treat them. The log showed her cancelling CT exams stating “no films” and they could have been reprinted from the scanner. The log showed her looking at exams and still cancelling them. The manager recommended to his immediate supervisor that Karen be terminated for poor work performance and willful tampering and falsification of medical records. She had cancelled over $300,000 worth of exams and delayed treatment to numerous patients. At least one surgery had to be delayed because the exam had to be repeated. This one employee harmed the reputation of the whole department and caused strife for other employees. The manager’s immediate supervisor, unfortunately, did not support the termination of this employee. Instead, this employee was reassigned different duties within the department. Evaluate the two questions and answer them following the writing guidelines. Questions: How do you feel about the decision to reassign this employee instead of terminating her? What decision would you make and why?

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