Real Time Abstraction A Multidisciplinary Approach

Multidisciplinary Team Clinical Care Excellence Team Nurse Manager Staff Nurse Charge Nurse Abstractors/Coders Pharmacy Social Worker/Utilization Review Respiratory Quality Risk Manager Admission Nurse/ Infection Control Surgical Team Member Registration/Insurance Verifier

Admission Nurse Role Patient Placement/Eligibility Completes Initial Interview Complete skin assessment Review all Present on Admission concerns Initiate the CMS indicators when appropriate Note and communicate risk for HAC Review all admissions completed on the off shifts for proper documentation Medication reconciliation at Admission Completes Admission worksheet and reports CMS indicator issues to staff nurse Report admitting diagnosis to coders Fax admission checklist to Medical Record 922-5279

Charge Nurse Role Attend daily Multidisciplinary Meeting at 10:00am Report on tentative discharge dates. Monitor Staff Nurse documentation for CMS compliance. Ensure follow through by staff nurses of items presented at Multidisciplinary Meeting. Staff nurse to report pending issues to charge nurse . Communicates if needed with physicians to ensure compliance with CMS indicators. Reviews daily census reports with History and daily vitals of all patients on floor. Maintains White message board in break room daily

Staff Nurse Clinical Time with patient Reports on patient to Multidisciplinary team at 10:00am. Clinical documentation Review Admission Nurse Checklist and follow-up on pending issues that have been identified. Obtains physician orders to comply with CMS indicators using standing orders or evidence based order sets. Views message board-post-it in EMR for issues from abstractor. Place action taken with date and time. Follows up on actions needed from message board in EMR on documentation required and or seeks physician orders to comply with CMS indicators. Rounds on patient

Abstractors Daily review of inpatients EMR and surgical schedule and ensure compliance with CMS Indicators. Attend daily Multidisciplinary meeting at 10:00 and report and follow-up on pending documentation issues. Comment in EMR on message board –Post-it documentation issues. Report any significant changes in care plan or diagnosis to coders and multidisplinary team. E-mail outstanding issues to nursing supervisor/charge.

Coder Assign a working DRG at admission based on admitting diagnosis and history and physical. Attend Multidisciplinary Meetings, present preliminary coding of cases to abstractors. Post changes to DRG through review of chart or through communication with abstractor in EMR through Post-it.

Pharmacist Medication Reconciliation Review at Admission, transfers and discharge Attend Multidisciplinary Meetings Communicate medication changes with physicians that are needed to meet CMS indicator medication requirements.

Social Worker/ Utilization Review Social Issues and Placement Attend all Multidisciplinary Meetings Ensure documentation of Care Conferences in patient chart. Confirm and communicate insurance data and eligibility. Report Insurance Status Appropriate use of level of care to ensure best reimbursement. Assign tentative discharge date and relays to team. Help team achieve discharge date

Multidisciplinary Team Meetings

Admission Checklist from Admission Nurse Program SAM-MC

COMMUNICATION Communication will be the Key to Success

Communication Standardize communication Use SBAR and standarized taxonomy S- situation; whats the problem B- background; the context, objective data, the numbers Assessment: whats the problem? Recommendation; what do we need to do and when? How are we going to fix it? What is needed from physician

COMMUNICATION Saves time for physicians, patients and staff Clear way to communicate Avoid staff and physician frustration Eliminate unnecessary information (hear-say, and opinions)

SBAR

COMMUNICATION Display results of CMS Indicator Scores and publically reported measures in all break rooms so all staff aware of our standing and update monthly. Continued education on CMS Indicators and future indicators.

Result Postings

Teamwork Enhance performance and ensure the best quality of care by team All of team on same page No idea or suggestion discouraged Every team member has a voice Brainstorm to achieve best outcome. Administrative support of team Include patient concerns

Goal Quality Care and the best evidence based practices given for our patients. 100% Compliance with CMS Indicators Obtain highest level of reimbursement Achieve above State and National scores on publically reported measures. Patient, Physician, and Staff Satisfaction

Work In Progress Bi-Weekly CMS Fallout meeting with nursing supervisors/Charge abstractors and quality. Keep identify what is working and not working or barriers to compliance. Hospitalist added to multidisciplinary daily meeting. Hospitalist follow-up with attending on issues identified at meeting. Address fallout's real-time with staff Continue letters to physicians on fallout's. CPOE/EBOS

Where are we now.

Thank You For your time and attention