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Enhancing Quality & Safety through CDI at Thomas Jefferson University Hospital

Learn how CDI specialists at TJUH leverage interventions to impact NHIQM, PSIs, mortality indices, and HACs, with a focus on pitfalls and best practices.

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Enhancing Quality & Safety through CDI at Thomas Jefferson University Hospital

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  1. The Impact of CDI on Quality and Safety Initiatives in an Academic Medical Center Tricia Norton, RN, BSN, CCDS Manager, Clinical Documentation Improvement Program Thomas Jefferson University Hospital Philadelphia, PA

  2. 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

  3. 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

  4. 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)

  5. NHIQM and the HQID Project

  6. 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

  7. 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

  8. NHIQM at TJUH Concurrent Intervention

  9. 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

  10. 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

  11. 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

  12. Surgical Care Improvement Project (SCIP)

  13. 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

  14. SCIP Core Measure Data from Premier, Inc. based on TJUH administrative data

  15. Acute Myocardial Infarction (AMI)

  16. 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

  17. 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

  18. AMI Core Measure Data from Premier, Inc., based on TJUH administrative data.

  19. Pneumonia

  20. CDIP Impact on PNA Measures • Diagnostic uncertainty • Healthcare-associated pneumonia • Pneumococcal vaccination status (patients>65) • Influenza vaccination status (patients>50; October-March)

  21. Pneumonia Core Measure Data from Premier, Inc., based on TJUH administrative data.

  22. Heart Failure

  23. CDIP Impact on Heart Failure • LVSF assessment • LVSD • Reason for no ACEI/ARB at discharge

  24. HF Core Measure Data from Premier, Inc., based on TJUH administrative data.

  25. NHIQM at TJUH Concurrent Intervention Tools

  26. NHIQM at TJUH: Retrospective Intervention

  27. TJUH Clinical 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

  28. 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

  29. 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  

  30. Additional Quality and Safety Initiatives

  31. 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.

  32. 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

  33. 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

  34. 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

  35. 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

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

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