Tricia Norton, RN, BSN, CCDSManager, Clinical Documentation Improvement ProgramThomas Jefferson University HospitalPhiladelphia, PA

The Impact of CDI on Quality and Safety Initiatives in an Academic Medical Center

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

Concurrent Intervention

NHIQM at TJUH

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– 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

88%

89%

90%

91%

92%

93%

94%

95%

2008Q2

2008Q3

2008Q4

2009Q1

2009Q2

2009Q3

2009Q4 2010Q1 2010Q2 2010Q3

Discharge Quarter

Ap

pro

pri

ate

Car

e S

core

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 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

88%

90%

92%

94%

96%

98%

100%

102%

2008Q2

2008Q3

2008Q4

2009Q1

2009Q2

2009Q3

2009Q4 2010Q1 2010Q2 2010Q3

Discharge Quarter

Ap

pro

pri

ate

Car

e S

core

Data from Premier, Inc., based on TJUH administrative data.

Pneumonia

CDIP Impact on PNA Measures

• Diagnostic uncertainty

• Healthcare-associated pneumonia

• Pneumococcal vaccination status (patients>65)

• Influenza vaccination status (patients>50; October-March)

Pneumonia Core MeasurePneumonia

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2008Q2

2008Q3

2008Q4

2009Q1

2009Q2

2009Q3

2009Q4 2010Q1 2010Q2 2010Q3

Discharge Quarter

Ap

pro

pri

ate

Car

e S

core

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

93%

94%

95%

96%

97%

98%

99%

100%

101%

2008Q2

2008Q3

2008Q4

2009Q1

2009Q2

2009Q3

2009Q4 2010Q1 2010Q2 2010Q3

Discharge Quarter

Acc

ou

nta

ble

Car

e S

core

(A

CS

)

Data from Premier, Inc., based on TJUH administrative data.

Concurrent Intervention Tools

NHIQM at TJUH

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.”

“PCI delayed due to waiting for the patient’s family to arrive.”

“SVG angiojet cath did not cross lesion. XMI catheter successfully crossed the stenosis. Flow reestablished after 30 min. delay.”

“Patient waiting for family and clergy to arrive-wishes to consult with them before PCI.”

“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.

Retrospective Intervention

NHIQM at TJUH:

TJUHClinical

Effectiveness Team

SCIP Missed

Opportunities Working Group

AMI/CAP Non-ED Missed

Opportunities Working Group

AMI/CAP ED Missed

Opportunities Working Group

HF Missed Opportunities

Working Group

Chest Pain Center Working Group

Clinical Effectiveness Umbrella

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

• Complications of anesthesia (PSI 1)

• Death in low mortality DRGs (PSI 2)

• Decubitus ulcer (PSI 3)

• Death among surgical inpatients with serious treatable complications (PSI 4)

• Foreign body left in during procedure (PSI 5)

• Iatrogenic pneumothorax (PSI 6)

• Selected infections due to medical care (PSI 7)

• Postoperative hip fracture (PSI 8)

• Postoperative hemorrhage or hematoma (PSI 9)

• Postoperative physiologic and metabolic derangements (PSI 10)

• 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)

Purple = PSIs to be reported online*PSI Composite score also to be reported

Patient Safety Indicators

PSI #3: Pressure Ulcer

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

2008 Q4 2009 Q1 2009 Q2 2009 Q3 2009Q4 2010Q1 2010Q2

Discharge Quarter

Rat

e p

er 1

000

pat

ien

ts

Data from UHC’s Quality and Safety Management Report (QSMR) based on TJUH administrative data.

Patient Safety Indicators

PSI #12: Postoperative PE/DVT

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

2008 Q4 2009 Q1 2009 Q2 2009 Q3 2009Q4 2010Q1 2010Q2

Discharge Quarter

Rat

e p

er 1

000

pat

ien

ts

Data from UHC’s Quality and Safety Management Report (QSMR) based on TJUH administrative data.

Patient Safety Indicators

PSI #15: Accidental Puncture/Laceration

0.00%

0.05%

0.10%

0.15%

0.20%

0.25%

0.30%

0.35%

0.40%

2008 Q4 2009 Q1 2009 Q2 2009 Q3 2009Q4 2010Q1 2010Q2

Discharge Quarter

Rat

e p

er 1

000

pat

ien

ts

Data from UHC’s Quality and Safety Management Report (QSMR) based on TJUH administrative data.

Patient Safety Indicators

PSI #6: Iatrogenic Pneumothorax

0.00%

0.01%

0.02%

0.03%

0.04%

0.05%

0.06%

0.07%

0.08%

0.09%

0.10%

2008 Q4 2009 Q1 2009 Q2 2009 Q3 2009Q4 2010Q1 2010Q2

Discharge Quarter

Rat

e p

er 1

000

pat

ien

ts

Data from UHC’s QSMR report based on TJUH administrative data.

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

0

50

100

150

200

250

2006-4

2007-1

2007-2

2007-3

2007-4

2008-1

2008-2

2008-3

2008-4

2009-1

2009-2

2009-3

2009-4

2010-1

2010-2

Ca

ses

Mean Number of Diagnosis Codes per Patient

4.0

4.5

5.0

5.5

6.0

6.5

7.0

7.5

8.0

20

06

-4

20

07

-1

20

07

-2

20

07

-3

20

07

-4

20

08

-1

20

08

-2

20

08

-3

20

08

-4

20

09

-1

20

09

-2

20

09

-3

20

09

-4

20

10

-1

20

10

-2

Quarter

Ca

ses

Data from UHC’s QSMR report based on TJUH administrative data.

Mortality O/E: A Work in Progress

TJUH Mortality Index

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

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

O/E

rati

o

Start of working group

Data from UHC’s Quality and Safety Management Report (QSMR) based on TJUH administrative data.

CDIP and Risk Adjustment Models

AHRQ Comorbidities

• Liver disease

• Peptic ulcer disease

• AIDS

• Lymphoma

• Metastatic cancer

• Coagulopathy

• Obesity

• Weight loss

• Fluid and electrolyte disorders

• Blood loss anemia

• Alcohol abuse

• 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

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

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

%30

Day

s R

ead

mit

Start of Project

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

Patient had a CAUTI

YES

Was the UTI POA? UTI within 48 hrs from discharge location Admitted with known diagnosis

NO

YES

Non-foley UTI

NO

YES Exclude

Did the pt have an indwelling urethral catheter within past 2 days?

YES

Was the urine culture sent at time of insertion (same day)?

Non-foley UTI

Urine culture with > 105 organisms and no more than 2 different organisms (exclude <104 organisms)

Patient had a CAUTI

Asymptomatic - exclude

NO

Exclude 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

YES

NO

Revised Version: 7/28/10

Author: TJUH Infection Control Department.

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

Risk Adjusted UHC

(Benchmarking Data)

CMS

(Hospital Compare/

Med Par Data)

U.S. News

Thompson Reuters

Miscellaneous Entities

Premier/

National Hospital

Quality Measures

Joint Commission Quality Net, APU, HQA

Internal Reporting

AAMC Comparison

Reporting

AHRQ Patient

Safety Indicators

Coded into administrative data and sent to:

Thank You!