Transcript Slide 1

The Impact of CDI on Quality and
Safety Initiatives in an Academic
Medical Center
Tricia Norton, RN, BSN, CCDS
Manager,
Clinical Documentation Improvement Program
Thomas Jefferson University Hospital
Philadelphia, PA
Topics to Be Covered
• Interventions used by clinical documentation specialists
in the academic medical center to impact:
– National Hospital Inpatient Quality Measures (NHIQM)
– Patient Safety Indicators (PSIs)
– Risk-adjusted mortality indices
– Hospital-acquired conditions (HACs)
– Readmission rates
• Potential pitfalls and best practices related to concurrent
NHIQM abstraction
• Tools used by documentation specialists to facilitate
concurrent NHIQM reviews
• Current impact and future goals
Thomas Jefferson University
Hospitals (TJUH)
• 957-bed tertiary care center in Philadelphia, PA
• 3 campuses:
– Thomas Jefferson University Hospital, Center City
Philadelphia
– Methodist Hospital Division, South Philadelphia
– Jefferson Hospital for Neuroscience, Center City
Philadelphia
• 46,000 discharges per year
• 1,149 medical staff
• 6,240 employees
Clinical Documentation
Improvement Program (CDIP)
• 9 FTEs
– 8 RN clinical documentation specialists (CDS)
– 1 RN CDIP manager
• Reporting structure:
– CDS>CDIP manager>Director of HIM>Chief medical
officer
• Program start date: 11/2005 (4 FTEs)
• Program re-structured: 5/2007 (8 additional
FTEs)
• Program re-re-structured: 1/2009 (9 FTEs)
NHIQM and the HQID Project
NHIQM and the HQID Project
• “Through the Premier Hospital Quality Incentive
Demonstration CMS aims to see a significant
improvement in the quality of inpatient care by
awarding bonus payments to hospitals for high
quality in several clinical areas, and by reporting
extensive quality data on the CMS web site.”
• “Under the demonstration, hospital performance will
be based on evidence-based quality measures for
inpatients with: heart attack, heart failure,
pneumonia, coronary artery bypass graft, and hip
and knee replacements.”
http://www.cms.gov/HospitalQualityInits/35_HospitalPremier.asp
NHIQM at TJUH
• Inpatient participation:
– SCIP
• 100% abstraction of hip/knee, colon surgery, hysterectomy,
vascular surgery, CABG/other cardiac surgery
• Sampling of other major surgery cases
– AMI
– CAP
– HF
NHIQM at TJUH
Concurrent Intervention
CDIP and NHIQM: The “Old” Way
• 2007: Increased hospital focus on QM
• 8 additional FTEs hired into CDIP
• Goal was concurrent CDS review of 100% of
QM cases (excluding weekends and one-day
stays)
• CDS created case in Premier and abstracted all
available information at that time
Pitfalls
• Principal diagnosis dependency
• Redundancy
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•
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•
– CDS/abstractor
Unnecessary focus on elements unable to be
impacted concurrently
“Culture of fear”
Staffing and process issues
Processes revised in January 2009
The Current Way!
• More streamlined process
• Goal: Concurrent review of
all 2-day-out charts
• Focus evenly weighed
between:
– DRG/reimbursement
– SOI/ROM
– QM
• 1-day-out review of PNA, AMI, and HF charts
– Based on admitting dx
• Query process escalated for QM queries
Surgical Care Improvement Project
(SCIP)
CDIP Impact on SCIP Measures
• Urinary catheter removal/reason for continuing
urinary catheterization
• Reason to extend antibiotics past 24h (48h)
• Reason for not administering beta blocker
during perioperative period
• Reason for not administering VTE prophylaxis/
VTE prophylaxis ordered/administered timely
SCIP Core Measure
SCIP
95%
Appropriate Care Score
94%
93%
92%
91%
90%
89%
88%
2008
Q2
2008
Q3
2008
Q4
2009
Q1
2009
Q2
2009
Q3
2009Q4 2010Q1 2010Q2 2010Q3
Discharge Quarter
Data from Premier, Inc. based on TJUH administrative data
Acute Myocardial Infarction (AMI)
CDIP Impact on AMI Measures
• Reason for no LDL assessment/LLA (statin) at
discharge
• Reason for no aspirin within 24 hours of arrival
• LVSD
• Non-primary PCI/reason for delay in PCI?
• Reason for no ASA/BB/ACEI/ARB/STATIN at
discharge
Chest Pain Committee (CPC)
• Clinical group designed to improve
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•
•
•
door-to-balloon (DTB) times
Two goals:
– Maintenance of Chest Pain Center certification
– 100% compliance with PCI measure
“Golden-rod” e-mails
Day 1: CDI review of chart
– Queries placed as necessary
– Collaboration with cath lab staff
CDI tracking spreadsheet
– # cases, # queries, interventions
– Collaboration with abstractors, present data to team
AMI Core Measure
AMI
102%
Appropriate Care Score
100%
98%
96%
94%
92%
90%
88%
2008
Q2
2008
Q3
2008
Q4
2009
Q1
2009
Q2
2009
Q3
2009Q4 2010Q1 2010Q2 2010Q3
Discharge Quarter
Data from Premier, Inc., based on TJUH administrative data.
Pneumonia
CDIP Impact on PNA Measures
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•
•
•
Diagnostic uncertainty
Healthcare-associated pneumonia
Pneumococcal vaccination status (patients>65)
Influenza vaccination status (patients>50;
October-March)
Pneumonia Core Measure
Pneumonia
100%
Appropriate Care Score
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2008
Q2
2008
Q3
2008
Q4
2009
Q1
2009
Q2
2009
Q3
2009Q4 2010Q1 2010Q2 2010Q3
Discharge Quarter
Data from Premier, Inc., based on TJUH administrative data.
Heart Failure
CDIP Impact on Heart Failure
• LVSF assessment
• LVSD
• Reason for no ACEI/ARB at discharge
HF Core Measure
Heart Failure
Accountable Care Score (ACS)
101%
100%
99%
98%
97%
96%
95%
94%
93%
2008
Q2
2008
Q3
2008
Q4
2009
Q1
2009
Q2
2009
Q3
2009Q4 2010Q1 2010Q2 2010Q3
Discharge Quarter
Data from Premier, Inc., based on TJUH administrative data.
NHIQM at TJUH
Concurrent Intervention Tools
Acceptable Documented Reasons for Delay in PCI
Documentation must be made clear somewhere in the medical record that (1) a “hold”, “delay,”
or “wait” in doing PCI/reperfusion/cath/transfer to cath lab actually occurred, AND (2)
that the underlying reason for that delay was non-system in nature. Examples of acceptable
documentation related to PCI delay:
(*Note: Reason must be documented by a physician or physician designee)
“PCI delayed due to delay in diagnosis.”
“PCI delayed due to atypical presentation in
the ED.”
“PCI delayed due to ___________” (other
diagnostic tests being performed, ex = Echo,
CT scan of chest, etc).
“PCI delayed due to intermittent hypotension
when crossing lesion.”
“Hold on PCI. Will do TEE to r/o aortic
dissection.”
“PCI delayed due to –No urgent need, well
beyond the window. (C/P greater than 24
hours, MI occurred yesterday but continues
with chest pain).”
“PCI delayed due to the patient’s anatomy
made the procedure technically difficult
requiring several guiding catheters and wire
attempts and balloon inflations to achieve the
final result.”
“PCI delayed due to history of C/P is __
months old and has had symptoms for ___
hours and patient’s EKG with STE shows Q
waves.”
PCI was delayed due to difficulty crossing the
lesion with______ to get to the ____________
stenosis.”
“SVG angiojet cath did not cross lesion. XMI
catheter successfully crossed the stenosis.
Flow reestablished after 30 min. delay.”
“PCI delayed due to waiting for the patient’s
family to arrive.”
“PCI delayed due to totally occluded vessel.”
PCI delayed due to patient’s behavior.”
“PCI delayed due to patient required
stabilization in the ED prior to transfer to the
cath lab.”
“PCI delayed due to patient / family initially
refused Cath lab but then decided to proceed
with procedure.”
“PCI delayed due to patient requiring
stabilization with Dopamine and fluids in the
ED.”
“PCI delayed due to difficulty communicating
treatment plan with patient. Had to wait for a
____________ interpreter.”
“PCI delayed due to patient’s inability to
consent initially. (Patient was initially
unresponsive upon presentation but then woke
up.”
PCI held due to patient refusal.
“Patient waiting for family and clergy to
arrive-wishes to consult with them before
PCI.”
NHIQM at TJUH:
Retrospective Intervention
Clinical Effectiveness Umbrella
TJUH
Clinical
Effectiveness
Team
SCIP
Missed
Opportunities
Working Group
AMI/CAP Non-ED
Missed
Opportunities
Working Group
AMI/CAP ED
Missed
Opportunities
Working Group
Chest Pain Center
Working Group
HF Missed
Opportunities
Working Group
Missed Opportunities Working
Groups
• SCIP, AMI/CAP (ED), AMI/CAP (non-ED), HF
• Interdisciplinary:
– Abstraction area supervisor
– CDIP manager
– Performance improvement (PI)
– Vice chairman for surgical quality and/or physician champion
– Nursing
– Information systems (IS)
• Review of failed cases (“missed opportunities”)
• E-mail notification of service/departments
• Physician education
– Practice education: physician champion via M&M meetings, grand
rounds, e-mails
– Documentation education: CDIP via in-service, e-mail, tip sheets
• All are subgroups of Clinical Effectiveness Team
HQID Award: Year 5
• Thomas Jefferson University Hospitals received
the highest overall monetary award for any
individual provider in year 5 of the project
• For year 5, there were 223 participating facilities
• TJUH received the highest award in the Surgical
Care Improvement Project (SCIP) focus area
and the 4th highest award in heart failure
• TJUH is one of an elite group of hospitals to
receive 10 or more overall awards
Additional Quality and Safety
Initiatives
QSMR
• Quality and Safety Management Report*
– Previously two separate committees:
• Mortality
• PSIs
– Now one committee with combined and additional
focus areas:
• Mortality
• PSIs
• HACs
*QSMR group name was taken from the UHC’s Quality and Safety Management Report. Our data is taken
from UHC’s Quality and Safety Management Report (QSMR) based on TJUH administrative data.
QSMR
• Functions of QSMR:
– Identify trends
– Initiate action plans for improvement
• Observed
• Expected
– Multidisciplinary approach
• Director HIM, CDIP manager, PI, risk management, chief
quality and patient safety officer, nursing VP, vice chairman for
surgical quality
– Chart review
• Documentation and/or coding opportunities?
– Education
CDI Role in QSMR
• CDIP manager member of group
• Chart reviews to identify potential
documentation/coding trends/opportunities
• Collaboration with PI on physician education
• Collaboration with chief patient safety officer to
identify and communicate documentation trends
to service lines
• Retrospective queries when necessary
QSMR: PSIs
• Developed and maintained by AHRQ, a sister
agency to CMS in the DHHS
• Focus on the quality of care for adults inside
hospitals
• Inpatient administrative data is used to capture
these potential hospital complications
• Nine will be initially reported on CMS’ website
via:
– www.cms.hhs.gov/HospitalQualityInits
– Eventual reporting on Hospital Compare
AHRQ Patient Safety Indicators
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Complications of anesthesia (PSI 1)
•
Death in low mortality DRGs (PSI 2)
•
Death among surgical inpatients
with serious treatable
complications (PSI 4)
•
•
•
Foreign body left in during procedure
(PSI 5)
•
•
•
Iatrogenic pneumothorax (PSI 6)
•
•
Postoperative hip fracture (PSI 8)
•
Decubitus ulcer (PSI 3)
Selected infections due to medical
care (PSI 7)
•
•
•
Postoperative hemorrhage or
hematoma (PSI 9)
•
Postoperative physiologic and
metabolic derangements (PSI 10)
•
Purple = PSIs to be reported online
*PSI Composite score also to be reported
Postoperative respiratory failure (PSI
11)
Postoperative pulmonary
embolism or deep vein thrombosis
(PSI 12)
Postoperative sepsis (PSI 13)
Postoperative wound dehiscence
(PSI 14)
Accidental puncture and
laceration (PSI 15)
Transfusion reaction (PSI 16)
Birth trauma – injury to neonate (PSI
17)
Obstetric trauma – vaginal delivery
with instrument (PSI 18)
Obstetric trauma – vaginal delivery
without instrument (PSI 19)
Obstetric trauma – cesarean delivery
(PSI 20)
Patient Safety Indicators
PSI #3: Pressure Ulcer
1.20%
Rate per 1000 patients
1.00%
0.80%
0.60%
0.40%
0.20%
0.00%
2008 Q4
2009 Q1
2009 Q2
2009 Q3
2009Q4
2010Q1
Discharge Quarter
Data from UHC’s Quality and Safety Management Report (QSMR) based on TJUH administrative data.
2010Q2
Patient Safety Indicators
PSI #12: Postoperative PE/DVT
3.00%
Rate per 1000 patients
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
2008 Q4
2009 Q1
2009 Q2
2009 Q3
2009Q4
2010Q1
Discharge Quarter
Data from UHC’s Quality and Safety Management Report (QSMR) based on TJUH administrative data.
2010Q2
Patient Safety Indicators
PSI #15: Accidental Puncture/Laceration
0.40%
Rate per 1000 patients
0.35%
0.30%
0.25%
0.20%
0.15%
0.10%
0.05%
0.00%
2008 Q4
2009 Q1
2009 Q2
2009 Q3
2009Q4
2010Q1
Discharge Quarter
Data from UHC’s Quality and Safety Management Report (QSMR) based on TJUH administrative data.
2010Q2
Patient Safety Indicators
PSI #6: Iatrogenic Pneumothorax
0.10%
0.09%
Rate per 1000 patients
0.08%
0.07%
0.06%
0.05%
0.04%
0.03%
0.02%
0.01%
0.00%
2008 Q4
2009 Q1
2009 Q2
2009 Q3
2009Q4
Discharge Quarter
Data from UHC’s QSMR report based on TJUH administrative data.
2010Q1
2010Q2
Improving Risk-Adjusted Mortality
• Mortality is typically expressed as a ratio of an
observed mortality rate to a risk-adjusted
expected rate
– Ratio is observed to expected (O/E)
• Two avenues for improvement:
1.Decrease observed
2.Increase expected
Initial Focus: Improve the E!
Cases with Palliative Care V-code
250
200
Cases
150
100
50
0
2006- 2007- 2007- 2007- 2007- 2008- 2008- 2008- 2008- 2009- 2009- 2009- 2009- 2010- 20104
1
2
3
4
1
2
3
4
1
2
3
4
1
2
Mean Number of Diagnosis Codes per Patient
8.0
7.5
7.0
Cases
6.5
6.0
5.5
5.0
4.5
4.0
2010-2
2010-1
2009-4
2009-3
2009-2
2009-1
2008-4
2008-3
2008-2
2008-1
2007-4
2007-3
2007-2
2007-1
2006-4
Quarter
Data from UHC’s QSMR report based on TJUH administrative data.
Mortality O/E: A Work in Progress
TJUH Mortality Index
1.60
1.40
O/E ratio
1.20
1.00
0.80
Start of working group
0.60
0.40
0.20
0.00
2007- 2008- 2008- 2008- 2008- 2009- 2009- 2009- 2009- 2010- 2010- 20104
1
2
3
4
1
2
3
4
1
2
3
Discharge Quarter
Data from UHC’s Quality and Safety Management Report (QSMR) based on TJUH administrative data.
CDIP and Risk Adjustment Models
AHRQ Comorbidities
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•
•
•
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•
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Liver disease
Peptic ulcer disease
AIDS
Lymphoma
Metastatic cancer
Coagulopathy
Obesity
Weight loss
Fluid and electrolyte disorders
Blood loss anemia
Alcohol abuse
•
•
•
•
•
•
•
•
•
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•
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Congestive heart failure
Valvular disease
Pulmonary circulation disorders
Peripheral vascular disorders
Hypertension
Paralysis
Other neurological disorders
Chronic pulmonary disease
Diabetes
Renal failure
Drug abuse
Psychoses
Depression
CDIP Impact on ROM
• There are a few key variables that impact almost
every MS-DRG
– Code for use of palliative care is in 1/3 of the models; when
–
–
–
–
we analyzed our data, only 60 patients in a year had the
code
The number of diagnosis codes that are applied to a
patient is a variable in the models; we had been capping at
15
There are 30 comorbid conditions that are of particular
interest in the models
Admission status was incorrectly coded as “elective”
instead of “urgent”
There are two proprietary “black box” variables that come
from the APR-DRG grouper that are key variables in the
models (severity of illness and risk of mortality)
And What Else?
CDIP and HF Readmission Rates
• Six Sigma project
• Multidisciplinary
• “Problem list initiative”
• Binder education
Heart Failure Readmissions
16.00
Start of Project
14.00
%30 Days Readmit
12.00
10.00
8.00
6.00
4.00
2.00
0.00
2007-4 2008-1 2008-2 2008-3 2008-4 2009-1 2009-2 2009-3 2009-4 2010-1 2010-2 2010-3
Discharge Quarter
Data from UHC’s QSMR report based on TJUH administrative data.
Clinical Group Memberships
• CA-UTI task force (HAC)
– If patient has foley and a UTI, CDS evaluates case
based on TJUH infection control and CDC guidelines
– If meets criteria, CDS queries MD. “Is patient’s UTI:
• Catheter-associated
• Not catheter-associated
• Unable to clinically determine whether catheter associated”
– CDIP and SCIP working group report cases of urinary
catheter not removed by end of postop day 2
• CA-UTI task force follows up with nursing or surgical team
CAUTI Definition/Algorithm
Final 1/14/09
Urine culture with > 105 organisms and no more
Patient had
CAUTI
than 2 different organisms (exclude
<104aorganisms)
NO
Exclude
YES
Was the UTI POA?
 UTI within 48 hrs from discharge location
 Admitted with known diagnosis
YES
Exclude
NO
Did the pt have an indwelling urethral catheter within
past 2 days?
NO
Non-foley
UTI
YES
Was the urine culture sent at time of insertion (same
day)?
YES
Non-foley
UTI
NO
Did pt have T>=100.4 w/I 48 hrs (w/o other cause)
OR
Suprapubic/ flank tenderness, urgency, dysuria
(usually cannot determine from JeffChart)
OR
pos blood culture w/ same organism
NO
Asymptomatic
- exclude
YES
Patient had a CAUTI
Author: TJUH Infection Control Department.
Revised Version:
7/28/10
Clinical Group Memberships
• HAPU (Six Sigma project)
– CDIP provides education related to documentation
and coding guidelines
– CDIP provides input regarding admission assessment
documentation of pressure ulcers
– CDIP queries for pressure sore/stage
– CDIP provides input for form revisions and education
Upcoming Opportunities …
•
•
•
•
Diabetes clinical group (HAC)
Sepsis clinical group (PSI)
CVC infection control group (HAC?)
Readmission rates among other diagnoses
– PNA
– AMI
– Etc.
• LOS
EDUCATION IS KEY!
What’s
in this
for me?
Physician
Documentation
Coded into administrative data and sent to:
Risk Adjusted UHC
(Benchmarking Data)
CMS
(Hospital Compare/
Med Par Data)
Internal Reporting
AAMC Comparison
Reporting
U.S. News
Thompson Reuters
Miscellaneous Entities
Premier/
National Hospital
Quality Measures
Joint Commission
AHRQ Patient
Safety Indicators
Quality Net, APU, HQA
Thank You!