Hospitals cannot live by DRGs alone: A focus on severity of illness and risk of mortality Tamara Hicks, RN, BSN, CCS Wake Forest University Baptist Medical Center Winston-Salem, NC May 2009

Agenda History of Clinical Documentation Management Program (CDMP) at WFUBMC Applying documentation improvement strategies to capturing severity of illness/risk of mortality: Querying for severity indicators Tracking severity of illness queries Focus on mortality Using Six Sigma methodologies to improve the process

Who we are NC Baptist Hospital (Wake Forest University Baptist Medical Center) 872 licensed beds Level 1 trauma center Brenner Children’s Hospital No obstetrics services

Payer mix Medicare—44% Medicaid—21% Other—35% Medicare CMI—1.80 (FYTD as of 11/2008)

CDMP at WFUBMC Program started in March 1999 Consulting firm identified need: Ernst & Young J.A. Thomas & Associates Initial focus on Medicare Medicaid added in 2001 Began 100% review regardless of payer in 2005

Staffing model of CDMP CDMP is one team in Department of Care Coordination Care Coordination reports to Quality Outcomes division 12 FTEs—CDMP 11 Clinical Documentation Consultants (CDC) 1 Supervisor CDCs are BSN prepared nurses with at least five years of clinical experience CDCs assigned by nursing unit

Program operations Guide/Trak application by J.A. Thomas & Associates used to document reviews and track performance Communication with coders: Daily Communication sheet Communication with MDs: Worksheet (electronic and paper) E-mail Page Face-to-face

SOI/ROM In 2005, via UHC (University HealthSystem Consortium), WFUBMC determined that the mortality index was greater than 1.0, suggesting that patients are dying more often than they should Looked to CDMP for help in reflecting true expected mortality

Mortality index Mortality index = Observed mortality Expected mortality Observed mortality—driven by quality- of-care initiatives Expected mortality—driven in large part by documentation

Mortality Index 2005 Compare of Hospitals of Like Size, CMI, Volume

CDMP response Integration of 3M APR encoder with Coding and Reimbursement software Used as resource for CDCs 100% review of all medical records, regardless of payer Queries related to severity More complete overall documentation

Severity queries Trach patients: CHF: Continue to review for severity: Malnutrition Pressure ulcers Electrolyte imbalances CHF: Acute systolic heart failure Chronic diastolic heart failure

Arrows and abbreviations Electrolytes i Na i K+ Anemia i hgb 1500 cc blood loss

Tracking queries Initially tracked by CDCs on separate form and entered into database by clerical staff: DRG queries Severity queries Eventually tracked via CDMP Guide No longer track queries separately Focus on complete documentation

Mortality Additional process of reviewing charts of all patients who expire In “prebill” phase, all “death charts” are reviewed by CDC who reviewed case concurrently Audit form used to capture any additional coding changes or need for additional documentation

Mortality (continued) Additional review conducted once APR SOI/ROM (severity of illness/risk of mortality) data available: Four levels of SOI/ROM: Minor Moderate Major Extreme Review of all cases not at 4/4 level Additional review once UHC data available: Review of all cases less than 20% expected mortality Review done by supervisors

Impact Adult Mortality Index Hospitals with less than 1,000 cases/quarter, Normal Newborns, OB April-December 2005 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 WFUBMC Mortality Index April-Dec 2004=1.09 April-Dec 2005=0.76 April-Dec 2005=0.75

Adult mortality

Success at what cost? Medical records of patients who expired were being reviewed up to three months after they died to capture the accurate expected mortality in the coded data The charts were reviewed multiple times because the needed documentation was not present in the medical record concurrently, resulting in the use of personnel resources and some loss of revenue

Enter Six Sigma Process improvement methodology Originally developed in the mid-1980s by Motorola Systematically designed a mechanism to standardize the measurement of process defects Its efforts lead to a $16 billion dollar savings At WFUBMC, Six Sigma began in 2003 Since 2004, the number of Six Sigma practitioners has increased, along with potential process improvement projects Starting in 2005, NCBH began to offer Green Belt training twice each year Wave VII began in March 2008

Problem statement Handout PDW. This will be updated as we make changes. But this is what we will start with. Medical records of patients who expire are being reviewed up to three months after they die to capture the accurate expected mortality in the coded data The chart is reviewed multiple times because the needed documentation is not present in the medical record concurrently, resulting in the use of personnel resources and loss of revenue Pg 22 22

Objective statement Now, you may think you have the answer to the problem. Hold that thought. We’ll get to that….eventually. We’re going to delve into the process itself more before we get to solutions. Improve cycle time of medical record review from 72.7 days after patient expires to 10 days or less after patient expires Pg 23 23

Using Six Sigma methods Team was created Six Sigma tools were used to define, measure, and analyze the problem The process was mapped out Improvements in process were identified Controls will be put into place after final analysis of improvements

Process Map

Improvements: Standard query process Standardization of query process: CDCs were each using their own process for querying MDs Standard was created from internal “best practice” CDCs with most “successful” query process utilized Examined query response rates

Query process

List of documents

Improvements: Standard query process The assumption was that there would be an increase in the number of queries per CDC and in the number of query responses by CDC There was an increase in the number of queries in the first four months, but there was not an increase in the query response during the same time

Query response NOTE from Editorial Services: The chart looks cut off at the bottom. Able to fix?

Improvements: Auditing of CDCs Ensure that concurrent process is being followed Ensure that all opportunities to improve documentation is being identified Staff accountability

Improvements: Auditing of CDCs Audit consists of: Initial review timely (within two business days) Follow-up review timely (every two business days) All opportunities identified Queries are appropriate (including wording and structure) Appropriate working DRG assigned Core measures identified Diagnoses identifying severity of illness documented on worksheet

Improvements: Auditing of CDCs The hypothesis was that there would be: An increase in the number of queries per CDC An increase number of query responses by CDC Improvement in the audit data Follow-up audit pending

Improvements: Auditing of CDCs (baseline)

Improvements: Shadowing The need was identified for coders and CDCs to better understand each other’s role Improve the ability to work together toward improved documentation

Improvements: Shadowing Shadowing pilot: Two CDCs and two coders spent two, two-hour blocks of time shadowing with a member of the opposite discipline Staff members observed key components of the job (abstraction of codes, chart review, interaction with MDs, etc.) A pre-shadowing survey conducted by project leader just prior to shadowing A post-shadowing survey conducted by project leader immediately following shadowing. Results analyzed and tested for statistically significant change

Improvements: Shadowing Hypothesis: There would be change in the understanding and appreciation of the CDC/coder's job after shadowing Statistical analysis of pre- and post-shadowing surveys show that the hypothesis is true and that there was positive change in the understanding and appreciation of the CDC/coder’s job after the shadowing exercise The shadowing process will be conducted with all existing staff and be incorporated into new employee orientation for CDMP

Improvements: Designated reviewer Designated reviewer of death charts during prebill phase: Identified need to have one or two consistent reviewers with expert knowledge Supervisors of CDCs and coders identified to review all death charts Discovered that workload was too heavy Pilot changed after two months Only records with SOI/ROM < 4/4 reviewed by supervisors; others reviewed by CDCs as before

Improvements: Designated reviewer The theory was that the number of changes required in final death chart reviews would be less after adding the designated reviewer The number of cases with change in expected mortality would be less after adding the designated reviewer

Improvements: Designated reviewer Data incomplete as of January 2009 Plan will be to discontinue the final review once data is analyzed

Other improvements Monthly review of Coding Clinics with quiz during Task Force meetings Specialty notebook for CDCs covering units that are unfamiliar Competencies/accountabilities for CDCs to be used for merit review Monthly report of MD query response to department heads Development of internal coding guidelines/ policies Education on writing queries (incorporated into audit)

Conclusions/lessons learned CDI strategies may be used to improve SOI/ROM Six Sigma methodology can be applied to clinical documentation improvement Even “mature” CDI programs can improve and remain successful

Questions? See Exhibits I1–I3 for additional resources