Quality

Steps Hospitalists Should Take to Reduce Turnaround Time of Death Certificates


 

Funeral-home representatives sometimes make multiple trips to a hospital or doctor’s office to get a death certificate signed, often waiting in the lobby for hours. I first realized this in the 1980s when starting post-residency practice as a hospitalist. I began asking these guys (they are nearly always men, in my experience) how much time they typically invest getting each certificate signed. They told of walking halfway across a golf course to catch the doctor on the 13th hole or making the 90-minute drive (each way) to a doctor’s office, sometimes finding the doctor had just left, only to repeat the process several times before getting the signature.

When the Clinton administration made electronic signatures via the Internet valid, I thought about starting a business charging funeral homes something like $200 for getting the doctor to sign it electronically within 48 hours. I would use about half of the $200 to provide an incentive for the doctor to sign quickly (sign within 48 hours, and you’ll get a $100 gift card!), then use the rest to fund the company. Since funeral homes probably spend much more than $200 per certificate paying their staff to drive around getting signatures on paper, I thought they would jump at this idea.

I never pursued it, but that doesn’t stop me from loudly proclaiming to friends and family that it was a “can’t-miss” blockbuster Internet business idea. Of course, I never tested that theory, but it makes for fun chest-thumping at parties.

Lack of a death certificate can hold up burial or cremation, and things like life-insurance payouts and estate settlement are delayed. For a grieving family, these things only add to their pain.

A number of states, including Florida, Texas, and others, now have in place online completion of death certificates. Indiana has required use of its online death certificate since 2011; there is no option to use paper. I suspect nearly every state will do the same before long. But that alone won’t ensure timely completion. Doctors and others who complete the certificates need to ensure they respond quickly, something they often fail to do.

It Really Matters

Lack of a death certificate can hold up burial or cremation, and things like life-insurance payouts and estate settlement are delayed. For a grieving family, these things only add to their pain.

I’m aware of a tragic case from a few years ago in which a certificate was passed around to a number of doctors, each of whom thought with some justification that someone else should sign it. It sat in two different mailboxes for many days while the intended recipients were vacationing. All of this delayed the burial, and the poor family had to send updates to loved ones saying, “We don’t know when Dad’s funeral will be.” About three weeks later, the certificate was completed and the funeral held. What a terribly sad story!

Some states have laws governing how quickly certificates must be signed. A thought-provoking 2004 Medical Staff Update from Stanford University says that California requires a signature within 15 hours of death, though I wonder how often this is enforced.

Improving Turnaround Time

There are several things hospitalists could consider to improve timely completion of death certificates:

  • Ensure doctors liberally complete them for one another. Don’t let one doctor’s absence delay, even for a day, getting it completed and signed. This means the “covering” doctor has access to the discharge (death) summary in the medical record.
  • When several doctors in different specialties are caring for a patient at the time of death, nearly any of them could reasonably sign the certificate. It might be appropriate to adopt a policy that whichever doctor (e.g. hospitalist, intensivist, or oncologist) who had contact with the patient and is presented with the certificate should go ahead and sign it rather than passing it along to one of the other specialties, regardless of which served as attending.
  • Consider creating a central access point at your hospital for receipt of death certificates. Ideally, a funeral-home representative can deliver it to one person at the hospital who will do the leg work of getting a doctor to sign it quickly. Delays are likely if the funeral-home representative has to “shop it around” to different departments and physician offices. A hospital staffer should be able to navigate this quickly.
  • Pressure EMR vendors to include some sort of death-certificate functionality in the future. I don’t know if some have it already, but it seems like it shouldn’t be too difficult for an EMR to spit out a prefilled certificate in much the same way e-prescribing works. It could even be delivered electronically to the funeral home.
  • For hospitalists with 24-hour, on-site presence, it could be reasonable to have an on-duty hospitalist complete the certificate at the time of death rather than waiting for the funeral home to initiate the process. This was standard when I was a resident, and it may be a practical approach in many settings.
  • Consider copying one hospital I worked with previously: They created a hospitalist salary bonus for timely completion. I assure you this policy was very effective.

Follow up on Direct Admissions

In the April 2013 issue, I wrote about the challenges associated with direct admissions (“Hospitalist Workload,” p. 69). I heard from a number of people, including Dr. Rob Young, a talented hospitalist who pointed me to a paper by his colleagues at Northwestern University (Am J Emerg Med. 2012;30(3):432-439). It makes sense that the safety of direct admission is influenced by the patient’s diagnosis, and sepsis patients are safer stopping in the ED first. And it can be tricky to sort all of this out in advance.

Dr. Mujtaba Ali-Khan, a hospitalist practicing in the Houston area, made me aware of the Direct Admission System for Hospitals (DASH), a commercial product he and a colleague have developed. I don’t have any experience with it and so can’t comment on its value, but you can learn more for yourself on YouTube (http://www.youtube.com/watch?v=HUG_vQgKvE0). What a clever idea for them to create a hospital “boarding pass” that the direct-admission patient presents on arrival to the hospital.

—John Nelson, MD, MHM


Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

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