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
Hospitals activities, and new facilities have been built to cater for the greatly
increased number or outpatients.
The rather unplanned and erratic nature of Anersley Hospitals 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 handpainted 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equally worn and out of date, and the actual filing racks were a home- made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 mut ual 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 wastepaper 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. Prices 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
Prices 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. Frasers 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. Prices desk. Mrs Price requested Mr.
Fraser to let her staff do an hours overtime each evening for a week to clear the backlog, but Mr. Fraser refused with the words If the clerks spent less time chatting, and
got on with the job theyre paid to do, thered be no problem the O & M team didnt
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 patients 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. Prices 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 oclock today in my office to find out why
this has occurred, and what we are going to do about it. Goodnight.