Quality Forum 2012BC Patient Safety & Quality Council

March 8, 2011

Gerald Yu, Director, CodingLower Mainland Health Information Management

Health Information Management Data Quality and Continuity of Care Improvement Project

At Vancouver Coastal Health

Health Information Landscape

Registration/AdmittingPatient Care Intake, Client Identity Mgmt, Data Guidelines

Records Management•Access to and Provision of Information

• Paper, Scanned, Electronic•QA: Documentation Requirements•Release of Information•Clinical Forms Mgmt

Care DeliveryPaper/Electronic

Record

Transcription ServicesStandardization of Dictated Reports

Coding and Abstracting

Budgeting Bed Allocation ResearchService Planning Education Performance MeasurementUtilization Mgmt

Introduction

Quality Patient Care is Dependent Upon:• Accurate, complete and timely documentation of a patient’s diagnosis, problems,

treatment and progress• Effective communication between physicians along the continuum of care

Physician documentation is important:• Increased reliance on structured/coded data with respect to funding, quality, planning

and research• Physicians are the key building blocks to creating and maintaining health data of the

highest quality

What does academia say about documentation?

• Van Walraven et colleagues found that the risk of re-hospitalization decreased when patients were assessed for follow-up by physicians who received a discharge summary

• Van Walraven and Rokosh have shown that family physicians rate discharge summaries as being high quality when they were short, delivered quickly, and contained pertinent hospitalization data.

• Ontario MOHLTC and CIHI found inadequate clinical documentation can lead to inaccurate code assignment, which leads to inaccurate representation of patient severity of illness

• Ontario MOHLTC found that only 11% of hospitals have discharge summaries completed within 48 hours

• Ontario Medical Association and the College of Physicians and Surgeons of Ontario recognized there is a serious gap in the education of new doctors as it relates to physician documentation

FACILITY TOTAL INPATIENT DISCHARGE SUMMARIES

(% DICTATED)

2006/2007 2007/2008 2008/2009

VGH 16 25 30

UBC 8 9 9

RH 69 74 78

LGH 21 26 31

N/A: Not available

VCH Environmental Scan - % of Dictated Discharge Summaries

Discharge Summary

7%

OR 5%

Consultation 7%

History/Physical 5%

Diagnostic Imaging

2%

Pathology 2%

Progress Note 11%

Face Sheet 62%

N/A: Not available

VCH Environmental Scan – What documents do diagnoses and interventions come from?

• 28% from electronic (dictation)• 73% from Handwritten• Internal audit showed dictated discharge

summary yielded higher Resource Intensity Weights (RIW) than handwritten face sheet

Objectives of the HIM Data Quality and Continuity of Care Project

1. Leverage the outcomes of complete, accurate and timely Health Record documentation re: Continuity of Care. * Complete and accurate coding and effective distribution of information.

2. Ensure that HA receives all funding applicable through Patient-Focused Funding (PFF). * Complete and accurate coding = accurate Resource Intensity Weight (RIW) reflecting service provided.

VCH Executive and HAMAC sponsored the improvement project. VCH Lean Transformation Services to provide support to HIM.

The Plan to Achieve the Objectives

1. Eliminate the handwritten face sheet (Discharge Summary/Discharge Instructions Form) and move to dictation for ALL inpatients with minimal exceptions

2. Create new Discharge Instruction form for patients and address the records with exceptions (i.e. <48 hour surgical cases).

3. Adopt and implement a standardized template for dictated Discharge Summaries - comprehensively reflects care delivered

4. Implement 48 hour post transcription distribution of Discharge Summaries

5. Implement standard QA Process and Implement Physician Suspension Process

6. Targeted physician engagement communication and education AND hire a physician educator

7. Increase physician awareness re: Distribution of Discharge Summary Reports (to community & referring physicians via auto faxed transcribed reports)

8. Increase Discharge Summary Report audit scope

9. Apply Lean methodology to HIM processes10. Go live on April 1, 2011

Standardized Discharge Summary Template

The Discharge Summary Template approved by the VCH Health Authority Medical Advisory Committee (HAMAC) provides a standard framework for physicians to consistently and effectively complete and communicate critical patient care information. The Discharge Summary should contain the following content if applicable.

1. Most Responsible Diagnosis 9. Names of Relevant Specialists 

2. Pre-Admit Diagnoses 10. Allergies

3. Post-Admit Diagnoses 11. Medications on Discharge

4. Secondary Diagnoses 12. Post-Discharge Follow-Up

5. Code Status 13. Discharge Disposition

6. Operative Interventions 14. Treatment/Course in Hospital

7. Other Interventions

8. Flagged Interventions Cardioversion Mechanical VentilationCell Saver ParacentesisCentral Lines - PICC/Portacath Per-orifice EndoscopyChemotherapy PleurocentesisDialysis TracheostomyEndoscopic/Percutaneous Biopsy RadiotherapyFeeding Tube Total Parenteral NutritionHeart Resuscitation

Discharge Summary Report Reference Cards

Physician documentation education module via Course Catalogue Registration System

The Health Record: Its Journey Through the Health Information Management Process

Discharge Summary Report

& Report Distribution

Target 4 days

Health Records: Pick up,

Assembly & QA for DSR

Day 3 to Day 10

Deficiency Loop: Notification to Suspension

LetterDay 38 to Day 66

Coding & Abstracting

Day 11 to Day 45

Submit Data to CIHI/MOH

Target 45 days

Patient Discharge

Physician Dictates2 days

Medical Transcriptionist

Transcribes2 days

40% DeficiencyAffects Coding

Accuracy & HIM Rework

40% DeficiencyAffects Coding

Accuracy & HIM Rework

Compliance ?Compliance ?

% Community & Referring Physicians Receive Reports at Milestones

50% 60% 75% 81% 86% 99%

Period End (PE = 28

days) + 28 Days =

Suspension

The Result: Timeliness of Completing Physician Dictated Summary Reports

Discharge (DC)

100% dictation

The Result: Discharge Summary Quality Audit

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Percent

Vancouver General Hospital

Comorbid Diagnosis by Patient Program

% Yes 89.7% 94.3% 87.3% 100.0% 98.0%

% No 0.0% 1.5% 5.7% 0.0% 2.0%

% P artial 10.3% 4.2% 7.0% 0.0% 0.0%

* Cardiac Surgery

Medicine Surgery Obstetrics P sychiatry

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Percent

Vancouver General Hospital

Most Responsible Diagnosis by Patient Program

% Yes 96.8% 95.3% 95.7% 100.0% 97.4%

% No 3.2% 0.4% 0.6% 0.0% 0.0%

% Inconsistent - MRDx 0.0% 4.3% 3.7% 0.0% 2.6%

* Cardiac Surgery

Medicine Surgery Obstetrics P sychiatry

Period reported from Dec 22, 2011 to Feb 1, 2012

Factors Influencing RIW Assignment

*PFF rate of reimbursement is currently set to $1,500 per acute RIW

55 year-old female with an admitting diagnosis of pneumonia. The patient came into hospital with ARDS, then developed C difficile, ventilated and also PICC line insertion.

Diagnosis/Intervention Diagnosis/Intervention RIW *PFF Cost

Most Responsible Diagnosis Pneumonia Unspecified 0.662 $993

Pre Admit Comorbidity ARDS 1.265 $1,897

Post Admit Comorbidity Enterocolitis due to C difficile 2.279 $3,418

Flagged Intervention Mechanical Ventilation 5.463 $8,195

Flagged Intervention PICC Line 7.094 $10,641

EXAMPLE

Issues and Challenges and Phase 2

1. Timely dictation of Discharge Summary within 48 hours after discharge• Improve physician notification process for discharge and deficiency

2. Continue physician engagement – currently physicians are reviewing the quality of discharge summary and indentifying barriers

• Make the reference card pocket size• Reference card App• Revise the online education module• Dictation system to prompt headings

3. To improve and sustain HIM processes• Smooth workflow (eliminate backlogs in each area)