Holly Flynn, RN, CCDS Medical Quality & Documentation Improvement Consultant

2. Case Study: How Partnership With Medical Directors, Clinical Integration Specialists, and Coders Impacts Patient Care Holly Flynn, RN, CCDS Medical Quality & Documentation Improvement Consultant Gene Peterson, MD, PhD, MHA Associate Professor of Anesthesiology, Associate Medical Director for Quality, and Codirector of the Center for Clinical Excellence University of Washington Medical Center, Seattle, WA

3. University of Washington Medical Center, Seattle (UWMC) Areas of specialization Cancer care, stem cell transplantation Solid organ transplantation – liver, kidney, heart, lung, pancreas, and intestine Neonatal intensive care, including the region’s first Level IIIB neonatal ICU UW Medical Center is part of the UW Medicine health system U.S. News & World Report’s 2011 edition of America’s Best Hospitals ranked UW Medical Center thirteenth in the nation in overall rankings Only five-time awarded Magnet Hospital for excellence in nursing care by the American Nurses Credentialing Center

4. Today’s Objectives • Discuss goals of “Concurrent Review of the Agency for Healthcare, Research, and Quality (AHRQ) Patient Safety Indicators (PSI) Project” at UWMC • Review the methodology, development, implementation, and evaluation of the project • Share lessons learned - Successes - Challenges - Results

5. ARHQ PSIs have … ... their roots in the Institute of Medicine's definition of patient safety: “freedom from accidental injury caused by medical care.” 1 This definition has since been expanded to include “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems.” 2

6. AHRQ PSIs – Background • AHRQ is a federal agency for research on healthcare quality, costs, outcomes, and patient safety • PSIs are a set of indicators providing information on potential for hospital complications and adverse events following surgeries, procedures, and childbirth • The determination of PSIs is based on ICD-9-CM codes assigned based on physician documentation in the medical record

7. Are PSIs Important? YES! • We are required to accurately describe all of our complications in the medical record, and the coded synopsis of our care needs to reflect this as well  • Once the documentation and coding are validated, all PSIs are “undesirable events” and represent patient harm, preventable or not • Good possibility that each of these PSIs will be attributed to individual physicians

8. UWMC’s Historical Look at PSIs • Historically UWMC has had a rather high rate of PSIs • May in part be due to our patient population? • Diligence in documenting what we do, while not being aware of how the documentation is reflected in the codes assigned?

9. PSI Composite FY2010 Baseline Events/1,000 eligible patients

10. How Do We Get This Right?

11. UWMC Goals • Low number of PSIs

12. PSI Project Timeline Methodology, planning, & development Implementation Project completion/ evaluation

13. Methodology, Planning, & Development • Intensive review of 215 cases that triggered PSIs, discharges beginning July 2010–December 2010 • Prioritize areas of action for patient safety • Understand PSI metrics • Analyze for clinical validity • Actual clinical event? • Documentation errors? • Coding errors? • Flawed metric?

14. Retrospective Review Findings • 65% cases of the PSIs were clinically valid • 30% cases were not clinically valid • 5% flawed metric

15. We Had to Get This Right • Low number of PSIs The cases which were not clinically valid were attributed to documentation and/or coding

16. PSI Project Team

17. PSI Project Team • Facilitated by UWMC medical executive leadership • Involve all stakeholders – compliance, HIM, coding hospital and physician, clinical integration specialists (CIS), medical executive leadership, and service chiefs • Clear definition of roles, expectations, and accountability for all team members

18. Implementation • Developed standardized language and education tools with input from all stakeholders • Created the “concurrent PSI review flow map” • CISs and coders worked with our physicians to ensure the medical records reflected accurate, complete, and compliant documentation • Corrected records were recoded and rebilled • All data was updated to reflect the changes and corrections

19. Concurrent PSI Review Process

20. Concurrent PSI Review Flow Map

21. Coding and CIS Team AHRQ software Coding runs a report from 3M for charts coded in the prior day to determine if a PSI will be triggered PSI triggered Coding e-mails CIS, medical quality – PSI(s) triggered, clinical documentation that supports assigning the codes that triggered the PSI(s) CIS review Doc clarification or discussion coding/CIS agreement no PSI – coding changed to reflect clinical documentation Coding/CIS agreement that PSI present – noted on shared spreadsheet for further review by medical quality

22. Quality Consultant Team • Troubleshoots ARHQ software • Validates the data by running the AHRQ report and review of PSIs reported to UHC • Data that falls out is sent to the team for review and validation • Responsible for organizational PSI data

23. Medical Quality Improvement Committee (MQIC) • MQIC is a physician-led multidisciplinary committee encompassing all core service lines engaged in patient care • Its goal is to continually promote quality improvement and enhance patient safety through its oversight and coordination of an ongoing standardized peer review process

24. MQIC – PSI Review Process

25. PSI 15 Accidental Puncture or Laceration

26. PSI 15 Accidental Puncture or Laceration Retrospective review • 998.2 Accidental puncture or laceration during a procedure Concurrent PSI review

27. PSI 15 Accidental Puncture or Laceration 998.2 Accidental puncture or laceration during a procedure Numerator Denominator Discharges among cases meeting the inclusion and exclusion rules for the denominator with ICD-9-CM code denoting accidental cut, puncture, perforation, or laceration during a procedure All surgical and medical discharges age 18 years and older defined by specific DRGs or MS-DRGs Exclude cases: • With principal diagnosis denoting accidental cut, puncture, perforation or laceration or secondary diagnosis present on admission • MDC 14 (pregnancy, childbirth, and puerperium) • With ICD-9-CM code for spine surgery

28. Physician Education Goals • Physician education spearheaded by medical executive leadership • Medical executive works in tandem with surgery CIS • Actively engage service chiefs • Service chiefs responsible for holding their faculty accountable • Must make it “easy” for our surgeons • Develop education tools and create OR/procedure note templates

29. Service Chief Letter Dear Colleagues – Accidental puncture or laceration is a Patient Safety Indicator (PSI #15) that is now being posted on the Web for all hospitals in the U.S. and soon to be reported on Physician Compare. The determination of this PSI is based on ICD-9-CM codes assigned based on physician documentation in the medical record. We are required to accurately describe all of our complications in the medical record, and the coded synopsis of our care needs to reflect this as well. Historically, UWMC has a rather high rate of recorded Accidental Puncture and Laceration, which may in part be due to the types of cases that are sent to us and in part due to our diligence in recording what we do while not being aware of how the documentation is reflected in the codes assigned. If the puncture, tear, capsular laceration, enterotomy, colotomy, serosal laceration, or other such event was essentially unavoidable due to the nature of the adhesions, the inflammation, the abscess, the tumor, or whatever was present during the operation, you must use the words “this was anincidental occurrence inherent to the surgical procedure” to correctly indicate this was not a complication. Please avoid putting any of these incidental and inherent occurrences under the heading of COMPLICATION in your operative record. This creates what is known in the coding and compliance rules as conflicting documentation. The coders are required by Medicare rules to code this as complication. You need to document these events under the heading FINDINGS or COMPLEXITY. If you think the injury was avoidable, then don’t use the words incidental and inherent and document the surgical finding under the heading COMPLICATIONS. Despite our best efforts, you may receive a query from the coder or clinical documentation specialist if there is further need for clarification. I expect those to be answered within a reasonable time and in a polite and responsive manner. I have instructed the coders and documentation specialists to copy me if they need to query you more than once about a single question. Thank you for your attention to this. Sincerely, E. Patchen Dellinger, MD Professor, Vice Chairman and Chief Division of General Surgery

30. Surgeons –What Do You Need to Do? • If the puncture, tear, capsular laceration, enterotomy, colotomy, serosal laceration, or other such event was essentially unavoidable due to the nature of the adhesions, the inflammation, the abscess, the tumor, or whatever was present during the operation, you must use the words “this was anincidental occurrence inherent to the surgical procedure” to correctly indicate this was not a complication

31. Surgeons –What Do You Not Do? • Put any of these incidental and inherent occurrences under the heading of COMPLICATION in your operative record • This creates what is known in the coding and compliance rules as conflicting documentation

32. What If It Is a True Complication? • Document your surgical finding under the heading COMPLICATIONS • Don’t use the words incidental and inherent

33. Example 1 FINDINGS There were very dense adhesions between the mid small bowel and the fibrosis of the mass of the sigmoid anastomosis to the left retroperitoneum …During mobilization of the mid small bowel, an unavoidable enterotomy and de-serosalization was created, which necessitated a small-bowel resection for its repair. This was an inherent part of the procedure given the intense fibrosis and not a complication. Complications None.

34. Example 2 – De-Identified/Modified Findings During division of the left hepatic vein at its confluence to the IVC, the IVC was injured requiring repair of a 7 mm venotomy. Significant hemorrhage requiring initiation of the massive blood transfusion protocol resulted. This also led to additional prolongation of the procedure. Complications IVC injury requiring repair and massive blood transfusion. (

35. Example 3 – De-Identified/Modified TECHNIQUE The mass is identified … Coming inferiorly, the right renal vein is identified. It is skeletonized along its superior aspect, and during the course of this a small breach is made in the anterior surface of the right renal vein. There is significant bleeding from this venotomy, which is unable to be controlled laparoscopically, and thus I made the decision to convert to open. COMPLICATIONS Renal vein bleeding requiring conversion to open.

36. PSI 15 Accidental Puncture or Laceration – MQIC Case Review • All PSI 15s are sent to service chiefs for chart review • Service chief or his/her designate will perform a chart review and respond/comment and assign a Quality Concern Score (QCS) to determine if the standard of care was met • PSI with QCS > 3 will be included in quarterly service report

37. PSI 15 Accidental Puncture or Laceration – Questions to Service Chief • Was there a technical competence or training issue involved in this case? • Was there an equipment problem leading to the puncture or laceration? • Was there a supervision issue of house staff involved in this case? • Was the problem recognized in a timely manner? • Was the treatment of the laceration or puncture done promptly and effectively? • Was there an explanation of the complication to the patient and family?

38. Challenges • Lack of understanding of the AHRQ tool and its limitations • Needed to be more consistent with our follow-up on physician education

39. Successes • Active engagement and commitment from the medical executive leadership • Focused on one PSI at a time • Replicated the standardized process with each PSI • Creativity was encouraged in problem solving • Established a process for review/clarification of PSIs prior to final billing

40. What Processes Has UWMC Developed? • Review process and systems • Validation of clinical documentation and coding • Review by service chief or departmental M&M for QCS score • MQIC review of all PSIs after departmental review • Roles and expectations • Multidisciplinary review when necessary • Well-defined role for MQIC • Collaboration • CCE (analytics and clinical documentation), finance (coding) compliance, medical leadership

41. Next Steps … • Increase CDP and coding staffing to review all potentially preventable complications (PSIs, HACs ...) and share information with appropriate teams • Expand the review process to the other areas and identify if documentation education and/or templates would help with reducing the non-PSIs • Create standardized documentation and coding practices across UW medicine • Automate the daily AHRQ report

42. References • Kohn LT, Corrigan JM, Donaldson MS, editors. To Err Is Human: Building a Safer Health System. A report of the Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 2000. • Quality Interagency Coordination (QUIC) Task Force. Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. A report to the President. Washington, DC: 2000. Available at www.quic.gov/report/fullreport.htm. Accessed May 2004.

43. Contact Information University of Washington Medical Center Gene Peterson, MD, PhD, MHA gpeterso@u.washington.edu Holly Flynn, RN, CCDS

44. Questions? In order to receive your continuing education certificate for this program, you must complete the online evaluation which can be found in the continuing education section at the front of the workbook.