human: cdi impact on patient safety indicators · ©2016 hcpro, a division of blr. all rights...

©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.

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Kathleen Shindle, RN, BSN, CCDS, CDIPAllison Clerval, RN, BSN, CCDS, CDIPClinical Documentation Supervisors

Thomas Jefferson University HospitalPhiladelphia, PA

To Err Is Human: CDI Impact on Patient Safety Indicators

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Identify strategies for CDI staff to recognize potential PSIs during concurrent review

– Recognize the inclusion and exclusion diagnoses and procedures

– Define CDI and coding role in impacting PSI

– Implement lessons learned from case study review

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Our Background

• Thomas Jefferson University Hospital

– Center City Campus

– Jefferson Hospital for Neuroscience (JHN)

– Methodist Hospital

– Abington Hospital/Aria Health

• Clinical documentation staff at TJUH, Inc.

– Senior director of HIM and clinical documentation

– Director of clinical documentation

– 3 clinical documentation supervisors

– 23 clinical documentation specialists


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Defining Patient Safety Indicators

• Medical errors

– Types of errors

– Causes

• U.S. healthcare system

– Patient care

– Expense

– Patient safety

• History

• Patient Safety Indicators

https://www.justice.org/what‐we‐do/advocate‐civil‐justice‐system/issue‐advocacy/medical‐errors

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Defining Patient Safety Indicators

• 25 Patient Safety Indicators

– Hospital‐Acquired Condition Reduction Program (HACRP)

– Hospital Value‐Based Purchasing Program (VBP)

– Inpatient Quality Reporting Program (IQR)

– PSI 90 for CMS

– PSI 90 for AHRQ

http://www.qualityindicators.ahrq.gov/Modules/PSI_TechSpec_ICD10.aspx

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Steps for Attendees to Answer/View POLLING QUESTIONS

1.Navigate to the event Agenda in the main menu

2. Tap the name of the current session to view the session details page

3. Tap Polls

4. Tap the name of the poll

5. Tap your answerchoice and then tap Submit


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• Does your CDI program query concurrently for patient safety indicators?

– Yes

– No

– Don’t know

Polling Question 1

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PSI 90 Timeline at TJUH

2014 2015 2016

Initiation

• Second‐level coding review

• Targeted physician education

• Researched use of AHRQ software

Continued growth

• Transitioned to Surgical Missed Opportunities Group

• Creation of Clinical Quality Metrics Group

• Clinical documentation quality coordinator

Evolution

• Continued physician education

• Staff education• Evolution of review

process• Physician peer review with

all PSIs

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Monitoring Patient Safety Indicators

• Building an interdisciplinary team– Clinical documentation

• Supervisors• Director

– Coding• Clinical documentation quality coordinator• Advisory coder/director

– Performance improvement• Nurses• Data analysts• Chief patient safety & quality officer

– Physicians – Respiratory therapy– CMO/CNO


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Defining PSI 90

• PSI 03 Pressure Ulcer Rate

• PSI 06 Iatrogenic Pneumothorax Rate

• PSI 07 Central Venous Catheter–Related Bloodstream Infection Rate

• PSI 08 Postoperative Hip Fracture Rate

• PSI 12 Postoperative Pulmonary Embolism or Deep Vein Thrombosis Rate

• PSI 13 Postoperative Sepsis Rate

• PSI 14 Postoperative Wound Dehiscence Rate

• PSI 15 Accidental Puncture or Laceration

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Risk Adjusting for PSI

http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V44/Risk_Adjustment_Tables_PSI_4.4.pdfhttp://www.qualityindicators.ahrq.gov/Downloads/Resources/Publications/2015/Empirical_Methods_2015.pdf

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PSI 90 Case Examples


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• Is your CDI staff educated on querying for PSI exclusion criteria?

– Yes

– No

– Don’t know

Polling Question 2

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PSI 3: Pressure Ulcers

Definition

Inclusion

Exclusion

Documentation that supports

coding

Documentation opportunities

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Query

Query Response

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PSI 6: Iatrogenic Pneumothorax

Definition

Inclusion

Exclusion


coding


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PSI 6: Iatrogenic Pneumothorax Technical Specifications


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Query

Query Response

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PSI 7: Central Venous Catheter–Associated Bloodstream Infection

Definition

Inclusion

Exclusion


coding


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XX


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Laboratory Findings

Treatment

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Query Response

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PSI 8: Postoperative Hip Fractures

Definition

Inclusion

Exclusion


coding



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PSI 9: Perioperative Hemorrhage & Hematoma

Definition

Inclusion

Exclusion


coding


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Acute blood loss anemia vs.

Hemorrhage complicating a procedure

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Operative Report

At the completion of the case, the neck was copiously irrigated. Valsalva was undertaken to make sure there was no bleeding and the nerve stimulated with 0.8 mA of energy. A parathyroid superiorly was identified in the neck and preserved.

Once the neck was deemed to be hemostatic, I then placed a 10‐French JP drain and closed the neck with 3‐0 Vicryl, 4‐0 Monocryl and Steri‐Strips.


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Query Response

Query

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PSI 11: Postoperative Respiratory Failure

Definition

Inclusion

Exclusion


coding


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PSI 12: Perioperative Pulmonary Embolism or Deep Vein Thrombosis

Definition

Inclusion

Exclusion


coding



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Query

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PSI 13: Postoperative Sepsis

Definition

Inclusion

Exclusion


coding



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Query

XXXX

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Query Response

Query


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PSI 14: Postoperative Wound Dehiscence

Definition

Inclusion

Exclusion


coding


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PSI 14: Postoperative Wound Dehiscence

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PSI 15: Accidental Puncture or Laceration

Definition

Inclusion

Exclusion


coding



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Query

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Query Response


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Surgical tips: Punctures & lacerations

Terms that indicate an accidental puncture or laceration

Terms that suggest a non‐accidental puncture or laceration

Inadvertent, inadvertently Complication Complicated by Accidental, accidentally Unintended Unintentionally Unexpected, Unexpectedly

To facilitate Necessary Required Intentional Intended Inherent Integral Routinely expected

https://www.uhc.edu/docs/49018566_PSI15ConsensusStatement.pdf

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PSI 90 Education

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PSI Education

Education

Staff

Physicians

Attribution policy

Coding

Guidelines

Tip cards


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PSI Education

Inclusions and exclusions

• Immunocompromised diagnoses

– Pancytopenia/neutropenia

– Chronic kidney disease (unspecified or stage V)/ESRD

– Severe malnutrition/nutritional marasmus

• Immunocompromised procedures

– Organ transplants

– Bone marrow transplants

• Coagulation disorders

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Using Data to Gain Physician Buy‐In

• Clinical quality metrics meeting

• Surgical missed opportunities meeting

• Physician champions

– Surgery

– Vascular medicine

– CMO

– Medicine hospitalist

• UHC Ranking

• U.S. News & World Report

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Evolution of CDI and Coding Roles

• PSI reviews

– Operative reports

– Querying

– Inclusions/exclusions

• Collaboration

– Concurrent versus retrospective

– CDI supervisors & quality coordinator

• Monitoring

– Spreadsheet

– Query reports


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PSI 90 Workflow Decision Tree

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CDI Role in Hospital‐Based Committees

• Clinical quality metrics– Core Measures

– PSI 90

• Surgical missed opportunities– PSI 4 Death Among Surgical Patients

– PSI 6 Iatrogenic Pneumothorax

– PSI 9 Perioperative Hemorrhage/Hematoma

– PSI 11 Postoperative Respiratory Failure

– PSI 13 Postoperative Sepsis

– PSI 15 Accidental Puncture/Laceration

• Hospital DVT group– PSI cases

– Line‐associated DVTs

– Hospital‐acquired DVTs

– Clinical interventions

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PSI 90 Progress in Action


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Upcoming Changes for PSI 90 for AHRQ

• Name change

• Removal PSI 07

• Number of component indicators increased

PSI 09

PSI 10

PSI 11

• Changes made to PSI 08, PSI 12, and PSI 15

• PSI Weight Shift

• Adoption by CMS

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Reflecting the True Clinical Picture

• True quality of patient care

• Create solutions

– Physician education

• Documentation

• Clinical

• Find better alternatives

– Devices

– Complications

• Meet the challenges ahead

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Thank you. Questions?

[email protected]@jefferson.edu

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.

human: cdi impact on patient safety indicators · ©2016 hcpro, a division of blr. all rights...

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