2. 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

3. 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

4. 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

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

6. 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

7. 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

8. 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)
Page
Face-to-face

9. 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

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

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

12. 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

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

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

15. 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

16. 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

17. 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

18. 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

19. Adult mortality

20. 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

21. 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

22. 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

23. 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

24. 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

25. Process Map

26. 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

27. Query process

28. List of documents

29. 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

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

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

32. 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

33. 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

34. Improvements: Auditing of CDCs (baseline)

35. 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

36. 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

37. 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

38. 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

39. 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

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

41. 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)

42. 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

43. Questions?
See Exhibits I1–I3 for additional resources