Taking Charge of Our Future

Key Hospital Initiatives 2009-2010

Shirley Schlessinger, MDAssociate 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:• 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

8DRG/BlackPacket/Trainer 1006.PPT ©2006, 3M. Confidential and Proprietary.

3M™ DRG Assurance™ Program

The Need

Physician Documentation is received in

CLINICAL terms

Documentation for coding, profiling &

compliance requires specificity in

DIAGNOSIS terms

The 3M™ DRG ASSURANCE™ Program creates a bridge between the gap.

Breakdown between the two

Two separate languages

9DRG/BlackPacket/Trainer 1006.PPT ©2006, 3M. Confidential and Proprietary.

3M™ DRG Assurance™ Program

Diagnostic Statements Impacting Profiles

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 .

Internal and General MedicineClinical 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 antibiotic to Fortaz/Gentamycin

Probable gram-negative pneumonia

Chest pain treated with Prevacid or nitrates Specify type or cause (angina, CAD, GERD, psychogenic, etc.)

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:

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

• 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 SmithMedicare DRG

66 Intracranial Hemorrhage or Cerebral Infarction w/o CC/MCC

CMS Wt: 1.0303 ALOS 3.8 GLOS 3.1

Principal Diagnosis

43491Unspecified 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 SmithMedicare DRG

65 Intracranial Hemorrhage or Cerebral Infarction w CC

CMS Wt: 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 Major Joint Replacement w/o MCC

CMS Wt: 1.9871 ALOS 4.0 GLOS 3.7   Principal DX   996.43 Prosthetic joint implant failure   Secondary DX 599 Urinary tract infection 780.97 Altered mental status 401.9 HTN 244.9 Hypothyroidism   Principal Procedure 81.52 Partial hip replacement   Estimated Payment: $15,800.85

Granny has surgeryMedicare DRG 469 Major Joint Replacement w MCC

CMS Wt: 2.6664 ALOS 8.4 GLOS 7.1   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

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

• 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 HospitalsWelcome 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

UNITED STATES

AVERAGE

MISSISSIPPI AVERAGE

Percentage for UNIVERSITY OF MISSISSIPPI MED CENTER

Percent of Surgery Patients Who Received Preventative Antibiotic(s) One Hour Before Incision if appropriate*

82% 77%83% of 718 patients2

Percent of Surgery Patients Who Received the Appropriate Preventative Antibiotic(s) for Their Surgery if appropriate*

90% 83%96% of 729 patients2

Percent of Surgery Patients Whose Preventative Antibiotic(s) are Stopped Within 24 hours After Surgery if appropriate*

78% 74%86% of 696 patients2

Percent of Surgery Patients Whose Doctors Ordered Treatments to Prevent Blood Clots (Venous Thromboembolism) For Certain Types of Surgeries if appropriate*

79% 70%88% of 345 patients2

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*

75% 66%83% of 345 patients2

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• 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