Guest Post: It begins and ends in Patient Safety

By Jocelyn E. Murray, RN, CCDS

My CDI journey began at a level one trauma and teaching hospital in New Mexico. I accepted a permanent recruitment position and relocated out west. I shifted my career role from case management into CDI Implementation. There, I reported directly to the Chief Safety Officer, a well-respected medical professor for the university.

The CDI program (CDIP) implementation focus at the university hospital was on patient safety. How else would I be enticed to change scope of practice? I wanted to continue my nursing mission and help insure quality patient care. The CDIP aimed to:

• Identify documentation omissions
• Capture unexpected postoperative events
• Clarify if the events were inclusions of care or unexpected outcomes
• Identify any adverse effects during the patient encounter

The CDIP focused on improved quality by means of safety and risk identification linked to inpatient care. We provided lunch-and-learn sessions for insight to the medical and surgical provider teams. The forums reviewed quality and safety findings, provided documentation education and launched a query process as part of the CDI review to obtain documentation clarification necessary. The CDI specialist acted in a liaison role to utilization review (UR)/case management, quality, and nursing, and raised awareness of the identified untoward events that occurred during inpatient care. The CDIP brought awareness to the multidisciplinary team and new processes of documentation capture were established. New processes of identification for early intervention were also an indirect result of the awareness.

It’s now eight years later, and CDIP expansion led to a nationwide implementation of necessary CDI software tools, the improvement in financial impact tracking and reporting, capture of secondary comorbid (CC/MCC) diagnoses, and recognition of APR-DRG severity of illness/risk of mortality (SOI/ROM) indicators. All actions assisted in the practice’s more accurate capture of patient acuity and identifying the severity of care provided.

Nevertheless, the CDIP role in quality and safety recognition has never faltered. Quality documentation and Value-Based Purchasing (VBP) data transparency kept a light on patient safety, and the lost revenue impact associated has now been identified. Patient safety indicator (PSI) reviews remain a key component of CDIP practice for documentation excellence. PSIs have a critical impact on practice performance and the identity of PSI exclusions can protect facilities from financial loss. A wide variety of agencies offer public reports comparing both hospitals and physicians, allowing the savvy patient to choose only the safest, highest rated medical and surgical care. Does your program have a clear picture of the report and what impact it makes?

The impact of imprecise documentation with inaccurate coded data is measurable. Consider a random consultant audit of 14 facility records, four of the records identify likely inaccurately coded cases triggering established PSIs. The inaccuracy carries an error weight of greater than 28% on both the practice and provider quality statistics and corresponding revenue impact. CDIP PSI audits are critical; they increase compliance adjustment and the ROI. CDI specialists with quality training insight recognize the key diagnostic terms required to accurately clarify untoward event documentation in a safety audit. The list includes some of the following:

• Inclusion
• Exclusion
• Clinically indicated
• Necessary
• Required
• Inherent
• Routinely expected

Patient safety queries and documentation integrity education will bring focus towards a greater understanding of the impact these specified diagnostic terms hold. A diagnosis identifying the condition as part of the post-operative and medical care will then also prevent a coded error.

In addition, PSI exclusions, as noted in the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators Enhanced Version 5.0 reference, provide insight into diagnoses that do not meet PSI definition if combined with other acuity indicators. To learn more about quality and safety documentation and reporting, click here. You’ll find great material for provider education as well.

Editor’s note: Murray is a senior CDI consultant for HIM services at ComforceHealth. Her subject matter expertise includes consultative CDI services, training and education, and implementation of new programs. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board. Advice provided is general. Contact Murray at jocelyn.murray@comforcehealth.com.