Six Sigma Coding

2. Fill in the Blanks At _____________ Hospital/ Healthcare System , our greatest source of value is ________________________.

3. Our greatest source of value�.

4. Medicine and Six Sigma

5. Six Sigma definition of defects A defect is any failure of a product or service to meet customer requirements. The "customer" may be the external consumer, or may be the next step of an internal process.

6. Six Sigma acceptable levels of defects: 10,000 inpatient coded cases

7. To define customer requirements, first identify the customer

8. HIM �Customers and Clients� Start with the question: Who are your customers and clients? What they expect from your services? What will exceed their expectations? What value do your customers assign to your services? Who is competing with your physician documenters for Their time Their resources Their satisfaction What�s in it for the physicians to attain six sigma in documentation? What do your insurers expect from your services? Compliance Accuracy Timeliness

9. The Questionnaire An effective tool if delivered successfully Can be used for internal customers, external customers, clients and personnel Best if the participation is near universal Best if structured so it can be answered honestly Our experiences at HP3 Customers and Clients Physicians Administrative staff Coders

10. Medicine and Six Sigma 1999 - Medical Errors 44 to 98 thousand deaths according to National Academy of Science�s Institute of Medicine Validated public perception More people than auto accidents Case of unintended human error Cost of $17 to $29 billion Upwards of $4,700 per admission

11. Anything Less is not Acceptable If we used four sigma or 99.379% accuracy rate: Adverse surgery - 1 in 150 surgical cases For surgery patients in the U.S., a 99.9% quality level would yield 70,000 patients annually with surgery performed on the wrong part of their body About 5000 adverse surgical cases per week Wrong medications 6 wrong medicines per 1000 doses Do the math 500 bed hospital 5 medications given 4 times per day 10,000 doses per day or about 60 errors per day

12. Anything Less is not Acceptable Lost revenue $1.2 million dollars for an institution which has $200,000,000 in revenue One in every 150 patients treated is dissatisfied Approximately 4 million babies are born in the U.S. annually. If the probability of taking home the correct baby was only 99.9%, then 4,000 families would leave with the wrong baby each year.

13. Six Sigma Thinking It is a way of thinking about our activities and our patients from all viewpoints Every medical procedure and every hospital activity can be broken down into steps There are a small finite number of steps that are responsible for most errors. Measurement in the medical world is traditionally based on outcome It should also be based on patient (customer) satisfaction Patients satisfied with Actual medical care The cost of the care Insurance claim processing

14. Six Sigma Thinking Changes can be affected in the short term - usually within a year. Goals can be incremental on the road to six sigma Targeted improvements Everything must be measured!

15. Clinical Areas of Most Concern Medication Administration Emergency department triage Bed assignment Site marking for surgical and other procedures Length of stay Patient falls Patient restraints Assignment of patient caregivers

16. HIM Areas of Concern Physician documentation Timeliness of physician generated documents History and physical Discharge summary Consultation Operative Reports Lab and X-rays Pathology Reports Electronic documents

17. HIM Areas of Concern Coding of physician documentation Assignment of DRGs CC capture Secondary diagnoses Grouping for Severity Accuracy level of reimbursement based on coding Storage Retrieval of information stored in medial records

18. HIM Processes Map the steps in each hospital information process Determine who are the customers who are affected Factor in Supply costs Paper Copying Ink Binding Disposal Compliance costs Transport costs Computer down time Find bottlenecks � a single source for a process step is a potential problem Find high error tasks

19. HIM Employees Choose carefully Job description with reality checks Productivity standards High quality and continuous training Evaluate often Assign tasks consistent with skill levels Don�t be afraid to prune for better overall growth and efficiency Give them a voice in the management of the processes they will follow Evaluate your institution and workplace culture

20. The Value of HIM Professionals Determine an accurate value based on time spent and hourly reimbursement. Evaluate training levels appropriate for level of work assigned Under trained Overqualified Too expensive for task done Skill matrix for employees Productivity Recognize the consequences of coder fatigue The query process Home coding Hidden administrative costs

21. The Information Supply Chain

22. Accurate Documentation Drives appropriate code selection for accurate reimbursement Supports the high quality care provided by the Hospital; Accurately reflects patient acuity levels and the care provided to decrease denials for payment; Is accurately and compliantly captured at the point of service; Meets JCAHO standards for clinical documentation; Reduces risks from incomplete or unclear documentation; Provides accurate data for Medicare quality indicators and hospital report cards

23. Six Sigma Methodology D M A I C

24. Attaining Six Sigma in Documentation Define Who are the customers, clients, and patients who will be affected Metrics Measure your results Report cards Software solutions Audits Analysis Medical record process assessment Improvement - be willing to fix the problems Education Clinical documentation improvement programs Change the culture Eliminate non value added activities Document the results Continuity Put in place a system that ensures continuity

25. Six Sigma Oriented CDI The CDI program is an example of how six sigma thinking can be applied to documentation. Looking at a CDI program is a good way to explain some key concepts of the six sigma approach A thorough familiarity with the Documentation supply chain elements and the culture of the hospital Initial assessment of the documentation process is done through a series of audits to measure the accuracy of documentation An HIM assessment is done simultaneously to examine the processes of the medical record department especially with regard to coding.

26. Six Sigma Oriented CDI An analysis of the accuracy of documentation and its impact on the revenue of the hospital is done with the CMI Navigator. This gives us the ability to define where the documentation problems exist within the institution. HIM processes are reviewed and the potential effects of concurrent querying The CDI program�s analysis is reviewed with the hospital administration. A commitment for more accurate documentation is made across a broad representation of the hospital staff and administration. The finance and HIM departments promote the CDI program and foster its development and implementation.

27. Six Sigma Oriented CDI The individuals who have important roles in the CDI are chosen based on the qualities that are essential to six sigma managers. Key individuals who will participate in the CDI are selected The consultant group - educating and advising The CDS � the coordinator of activity Other members of the documentation team Distinct processes are analyzed and broken down into steps. The areas which account for the largest number of errors are isolated. Targets are set for documentation improvement

28. Six Sigma Oriented CDI Benchmarks are set for the CDS, and HIM professionals A report card system is put into place to assess the coders The CDI monitor system is put in place to measure all aspects of the documentation process. The CDI Monitor measures the key metrics on a continuing basis The results of these metrics are communicated throughout institution Improvement in the documentation culture of the hospital is effected

29. Six Sigma Oriented CDI Continuity is assured by Constant monitoring of the facility using the CDI monitor and the CMI navigator Follow up visits by the consultant groups retrains your CDS staff Processes are reviewed on a monthly basis for 12 months and then as needed Report card with specific metrics are prepared for the coders, CDS, and the physicians.

30. MEASUREMENT AND STANDARDS

31. Six Sigma is driven by:

32. Clinical Documentation & Coding �Customer� Requirements

33. Six Sigma Methodology D M A I C

34. Six Sigma Methodology & Coding

35. Six Sigma Methodology & Coding

36. Six Sigma Methodology & Coding

37. Six Sigma Methodology & Coding

38. Six Sigma Methodology & Coding

40. Physician� Report Card

41. Documentation Specialist Fitness� Report Card

43. Documentation & Coding Report Card

44. Coder Report Card

45. Documentation Specialist Report Card

46. Physician Report Card/Key Metrics

47. TOOLS AND TECHNOLOGY

48. Evolution of Computer Assisted Disease Classification

49. Coding Tools and Methods Software products that can �read� a provider�s transcribed medical documentation (natural language processing) and determine the appropriate CPT and ICD9-CM codes Highly proprietary machine learning based artificial intelligence program Software engine with the entire medical nomenclature and lexicon of the National Library of Medicine, the International Classification of Diseases and Current Procedural Terminology Speech to text products and checklist style electronic medical records Coderyte, Salor compliance+Coderyte, Salor compliance+

50. Coding Tools and Methods Some systems include logic for determining the use of add-on codes (modifiers) and multiple/bundled procedures Medicare coding initiatives and edits built in Some systems require provider to dictate in a prescribed template format others use natural dictation style both typically review electronic text files (i.e., transcribed report) and assigns codes Coders become editors of the computer assigned codes and the cases which the software was not able to make a coding assignment

51. Six Sigma Methodology

52. Increased Granularity of Data = Improved Data Quality? ICD-9-CM 13,000 diagnostic codes and 4,000 procedure codes representing the clinical aspects of episode of care

53. HL7 EHR System Functional Model Direct Care Examples: DC.1.1.3.1 Manage Problem List A problem list may include, but not be limited to chronic conditions, diagnoses or symptoms, functional limitations, visit or stay specific conditions. DC.1.1.3.3 Manage Allergy and Adverse Reaction List Allergens including immunizations and substances are identified and coded whenever possible and the list is maintained over time. All pertinent dates and including patient reported events are stored and the description of the allergy and adverse reaction is modifiable over time.

54. HL7 EHR System Functional Model Supportive EHR Examples: S.2.1.1 Outcomes Measures and Analysis Support the capture and reporting of information for the analysis of outcomes of care provided to populations in facilities, by providers and in communities. S.2.1.2 Performance and Accountability Measures Support the capture and reporting of quality, performance and accountability measures to which providers/facilities/delivery systems/communities are held accountable including measures related to process, outcomes and/or costs of care and may be used in pay for performance monitoring and adherence to best practices.

55. HL7 EHR System Functional Model Supportive EHR Examples: S.2.2 Report Generation A user can create standard and ad hoc reports for clinical, administrative and financial decision making . Reports may be linked with financial and other external data sources. S.3.1.2 Encounter Specific Functionality As an example, a pediatrician is presented with diagnostic and procedure codes related to pediatrics. Business rules enable automatic collection of necessary data from the patient�s health record and patient registry.

56. Six Sigma Methodology D M A I C

57. HP3 Six Sigma Services D M A I C

58. If you can�t measure it, you can�t manage it�

59. Thank you! Ian Diener idiener@hp3.com Ruthann Russo rarusso@hp3.com