Transcript This would be title slide - University of Mississippi Medical Center

Taking Charge of Our Future
Key Hospital Initiatives 2009-2010
Shirley Schlessinger, MD
Associate Dean for Graduate Medical Education
Be Aware!
• Recent Joint Commission Survey
• DRG Assurance Program is on-going (are we
documenting all our patient’s problems?)
• “Present on Admission” documentation means
saving the hospital money
• National Patient Safety Goals have been updated
• Hospitalcompare.gov / CMS reporting—We can do
better!
• UHC Benchmarking- ditto
• Organ Donation / Conversion Rates can be better!
TJC: The “Joint”
• TJC accreditation of our hospitals is critical
for training program accreditation
• Site survey in February 2009 with Continued
Accreditation, but Opportunities identified
• We have done poorly in a number of areas
because of PHYSICIAN behaviors!
Key Problem Areas:
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Must DATE and TIME all orders
Do NOT use “unacceptable abbreviations”
Avoid DOSE-RANGE orders
No verbal orders except in emergencies; telephone
orders to be co-signed within 24 hours
Orders, Notes, and SIGNATURES must be legible!!!!!
H&P or update must be completed within 24 hours of
admission
Medication Reconciliation FORMS must be completed
with status changes
TIME-OUT & Hand-washing still problems!
The DRG Assurance Program:
A performance improvement program utilizing
a concurrent review process
to
promote accurate DRG classification according
to the regulatory compliance standards set
forth by CMS
3M™ DRG Assurance™ Program
The Need
Breakdown
between the two
Physician
Documentation
is received in
CLINICAL terms
Two separate
languages
Documentation for
coding, profiling &
compliance requires
specificity in
DIAGNOSIS terms
The 3M™ DRG ASSURANCE™ Program creates a
bridge between the gap.
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DRG/BlackPacket/Trainer 1006.PPT
© 2006, 3M. Confidential and Proprietary.
3M™ DRG Assurance™ Program
Diagnostic Statements Impacting Profiles
Internal and General Medicine
Clinical Statement
(Cannot assign an ICD-9 code)
Diagnostic Statement
(When the corresponding diagnostic statement is provided, an
ICD-9 code can be assigned)
LUL infiltrate
LUL pneumonia
Hgb 5.2; transfused
Acute or chronic blood loss anemia
Emaciated; total protein/albumin low; nutrition
supplements started
Malnutrition (specify type)
ABG 7.22/68/44; will treat accordingly
Respiratory failure, acidosis, alkalosis, etc.
Will rehydrate patient
Dehydration, hypovolemia
BP 70/40 on Dopamine for support
Shock; cardiogenic, hypovolemic
Cardiac enzymes elevated; EKG positive
Acute MI
No overt CHF; will continue Lasix and Lanoxin
Compensated CHF
Unable to void; cathed for 600 cc
Urinary retention
Sputum gram stain with gram-negative rods; will change Probable gram-negative pneumonia
antibiotic to Fortaz/Gentamycin
Chest pain treated with Prevacid or nitrates
Specify type or cause (angina, CAD, GERD, psychogenic, etc.)
Diagnoses documented solely on diagnostic reports are not “codable.” The physician must
clinically correlate diagnoses with abnormal findings in the body of the medical record .
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DRG/BlackPacket/Trainer 1006.PPT
© 2006, 3M. Confidential and Proprietary.
Documentation
• Reflects the care you provided
• If it’s not documented, “it” never happened
• Reflects severity of illness through selection of:
– Principal Diagnosis
– Secondary Diagnoses
– Procedures Performed
General Rules Regarding Secondary
Diagnoses
Secondary diagnoses require at least one of the
following:
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Clinical evaluation
Therapeutic treatment
Diagnostic procedures
Extends length of hospital stay
Increased nursing care and/or monitoring
Probable, Possible, Suspected, and
Unable to Rule Out
In the inpatient setting you may use the
Probably, Possible, Suspected and unable to
Rule Out.
If the condition is Ruled Out then state such
and it will not be coded.
Our Goal
Accuracy
Accurate documentation appropriately reflects
the severity of illness of our patients and
the most accurate risk of mortality.
Medicare Changes- “POA”
• Present on Admission = POA
– To better measure hospital performance (good
and bad)
– To increase validity of hospital report cards
related to quality
– Distinguish between pre-existing conditions and
hospital acquired conditions ($$)
Identified Conditions
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Decubitus Ulcers
Catheter Associated UTIs
Vascular Catheter Associated Infections
Falls, Burns – Trauma while inpatient
Mediastinitis that Follows Heart Surgery
Object Left in Surgery
Air Embolism
Blood Incompatibility
Potential Implications to UMHC
• Our public image
• Financial
Patient: Granny Smith
Medicare DRG
66
CMS Wt:
Intracranial Hemorrhage or Cerebral Infarction w/o CC/MCC
1.0303 ALOS 3.8
GLOS 3.1
Principal Diagnosis
43491
Unspecified cerebral artery occlusion with cerebral
infarction
Secondary Diagnoses
27651
Dehydration
4019
Essential hypertension
78097
Altered Mental Status
2449
Hypothyroidism
2724
Hyperlipidemia
Estimated Payment:
$8,192.65
Granny Smith
Medicare DRG
65
CMS Wt:
Intracranial Hemorrhage or Cerebral Infarction w CC
1.1901 ALOS 5.3
GLOS 4.3
Principal Diagnosis
43491
Unspecified cerebral artery occlusion with cerebral infarction
Secondary Diagnoses
99664
Infection / inflammation due to indwelling urinary catheter
27651
Dehydration
4019
Essential hypertension
78097
Altered Mental Status
2449
Hypothyroidism
2724
Hyperlipidemia
5990
Urinary tract infection
Principal Procedure
5794
Insertion of indwelling urinary catheter
Estimated Payment:
$9,463.34
What does this mean?
• Last year if the patient developed a UTI post
catheter placement we were paid $9463.34
• NOW, we are not reimbursed the additional
$1,270.69
Granny has surgery
Medicare DRG
470
CMS Wt: 1.9871
Major Joint Replacement w/o MCC
ALOS 4.0
GLOS 3.7
Principal DX
996.43
Prosthetic joint implant failure
Secondary DX
599
780.97
401.9
244.9
Urinary tract infection
Altered mental status
HTN
Hypothyroidism
Principal Procedure
81.52
Partial hip replacement
Estimated Payment: $15,800.85
Granny has surgery
Medicare DRG
469
Major Joint Replacement w MCC
CMS Wt: 2.6664
ALOS 8.4
Principal DX
996.43
Prosthetic joint implant failure
Secondary DX
707.03
Decubitus ulcer, lower back
599.0
Urinary tract infection
780.97
Altered mental status
401.9
HTN
244.9
Hypothyroidism
Principal Procedure
81.52
Partial hip replacement
Estimated Payment:
$21,202.45
GLOS 7.1
What does this mean?
• Last year if the patient developed a
decubitus while hospitalized we were paid
$21,202.45
• Now, we are not reimbursed the additional
$5,401.60
What can you do?
Complete initial admission assessments to include visual
inspection of the skin
Document all findings in the medical record
Remember possible, probable and suspected are ok to use
in the inpatient setting
Wash your hands
Follow all protocols for dressing changes, IV line insertions
and care, foley cath insertions and care
National Patient Safety Goals
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Identify patients correctly
Improve staff communication
Use medications safely
Prevent infection
Accurately reconcile medications across the continuum
of care
Prevent patients from falling
Help patients to be involved in their care
Identify patient safety risks
Improve recognition and response to changes in
patient’s condition
Prevent errors in surgery
Hospital Compare - A quality tool for adults, including people with Medicare
Find and Compare Hospitals
Welcome to Hospital Compare. This tool provides you with information on how well the hospitals
care for all their adult patients with certain conditions or procedures. This information will help you
compare the quality of care hospitals provide. Talk to your doctor about this information to help you,
your family and your friends make your best hospital care decisions.
Hospital Compare was created through the efforts of the Centers for Medicare & Medicaid Services
(CMS), the Department of Health and Human Services, and other members of the Hospital Quality
Alliance: Improving Care Through Information (HQA). The information on this website has been
provided primarily by hospitals that have agreed to submit quality information for Hospital Compare
to make public.
Hospital Process of Care
Measure
Percent of Surgery Patients Who
Received Preventative
Antibiotic(s) One Hour Before
Incision if appropriate*
Percent of Surgery Patients Who
Received the Appropriate
Preventative Antibiotic(s) for
Their Surgery if appropriate*
Percent of Surgery Patients
Whose Preventative Antibiotic(s)
are Stopped Within 24 hours
After Surgery if appropriate*
Percent of Surgery Patients
Whose Doctors Ordered
Treatments to Prevent Blood
Clots (Venous
Thromboembolism) For Certain
Types of Surgeries if
appropriate*
Percent of Surgery Patients Who
Received Treatment To Prevent
Blood Clots Within 24 Hours
Before or After Selected
Surgeries to Prevent Blood Clots
if appropriate*
UNITED
STATES
AVERAGE
MISSISSIPPI
AVERAGE
82%
77%
83% of 718 patients2
90%
83%
96% of 729 patients2
78%
74%
86% of 696 patients2
79%
70%
88% of 345 patients2
75%
66%
83% of 345 patients2
Percentage for UNIVERSITY OF
MISSISSIPPI MED CENTER
University Hospital Consortium
(UHC) Benchmarking:
• Similar to CMS reporting, but a broader
range of measures
• Compares us to other Academic Medical
Centers
• We are making progress, but many
opportunities for performance improvement
JCAHO REQUIREMENTS
• Federally identified OPO
• Procedures in place for notifying OPO in
a “timely manner” of deaths
and/or impending deaths
• Procedures in place for notifying family of
donation option by trained requestor
• Written documentation of consent or decline
• Hospital works with OPO to educate staff on
donation issues
• 2005 “Conversion Rates” Focus----75%!!!
Organ Donation at UMHC
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2006 conversion 34%
2007 conversion 63%
2008 conversion 72%
To date 2009 conversion rate 53%
• Active “Donation after Cardiac Death” protocols
• Brain Death declaration check sheets available
• Potential Donor management protocols available
The Potential Organ Donor
Absolute Exclusions
• Active UNTREATABLE infection
• CURRENT malignancy
(Specific ORGAN failure may rule out
organ but NOT donor!)
Consent for Organ Donation
• Federal regulations mandate ONLY “trained
requestors” approach families for donation
consent
• Minimal acceptable “training” 8 hours
• Numerous variables are felt to impact
families likelihood to donate
• Consent is a PROCESS not a QUESTION!
What YOU Can Do…
• Learn the FACTS about organ donation
• Decide your personal donor status
• Tell your family and friends about your donation
wishes
• Look for opportunities to help others learn about
donation
• Talk to your patients about donation in advanced
directive discussions
• ALWAYS follow hospital and federal regulations
regarding offering families donation option