Download - Taking Charge of Our Future
Taking Charge of Our Future
Key Hospital Initiatives 2009-2010
Shirley Schlessinger, MDAssociate Dean for Graduate Medical Education
Be Aware!• Recent Joint Commission Survey• DRG Assurance Program is on-going (are we
documenting all our patient’s problems?)• “Present on Admission” documentation
means saving the hospital money• National Patient Safety Goals have been
updated• Hospitalcompare.gov / CMS reporting—We
can do better!• UHC Benchmarking- ditto• Organ Donation / Conversion Rates can be
better!
TJC: The “Joint”
• TJC accreditation of our hospitals is critical for training program accreditation
• Site survey in February 2009 with Continued Accreditation, but Opportunities identified
• We have done poorly in a number of areas because of PHYSICIAN behaviors!
Key Problem Areas:• Must DATE and TIME all orders• Do NOT use “unacceptable abbreviations”• Avoid DOSE-RANGE orders• No verbal orders except in emergencies;
telephone orders to be co-signed within 24 hours• Orders, Notes, and SIGNATURES must be
legible!!!!!• H&P or update must be completed within 24
hours of admission• Medication Reconciliation FORMS must be
completed with status changes• TIME-OUT & Hand-washing still problems!
The DRG Assurance Program:
A performance improvement program utilizing
a concurrent review process
to
promote accurate DRG classification according to the regulatory compliance
standards set forth by CMS
8DRG/BlackPacket/Trainer 1006.PPT ©2006, 3M. Confidential and Proprietary.
3M™ DRG Assurance™ Program
The Need
Physician Documentation is received in
CLINICAL terms
Documentation for coding, profiling &
compliance requires specificity in
DIAGNOSIS terms
The 3M™ DRG ASSURANCE™ Program creates a bridge between the gap.
Breakdown between the two
Two separate languages
9DRG/BlackPacket/Trainer 1006.PPT ©2006, 3M. Confidential and Proprietary.
3M™ DRG Assurance™ Program
Diagnostic Statements Impacting Profiles
Diagnoses documented solely on diagnostic reports are not “codable.” The physician must clinically correlate diagnoses with abnormal findings in the body of the medical record .
Internal and General MedicineClinical Statement
(Cannot assign an ICD-9 code) Diagnostic Statement
(When the corresponding diagnostic statement is provided, an ICD-9 code can be assigned)
LUL infiltrate LUL pneumonia
Hgb 5.2; transfused Acute or chronic blood loss anemia
Emaciated; total protein/albumin low; nutrition supplements started
Malnutrition (specify type)
ABG 7.22/68/44; will treat accordingly Respiratory failure, acidosis, alkalosis, etc.
Will rehydrate patient Dehydration, hypovolemia
BP 70/40 on Dopamine for support Shock; cardiogenic, hypovolemic
Cardiac enzymes elevated; EKG positive Acute MI
No overt CHF; will continue Lasix and Lanoxin Compensated CHF
Unable to void; cathed for 600 cc Urinary retention
Sputum gram stain with gram-negative rods; will change antibiotic to Fortaz/Gentamycin
Probable gram-negative pneumonia
Chest pain treated with Prevacid or nitrates Specify type or cause (angina, CAD, GERD, psychogenic, etc.)
Documentation
• Reflects the care you provided
• If it’s not documented, “it” never happened
• Reflects severity of illness through selection of:– Principal Diagnosis– Secondary Diagnoses– Procedures Performed
General Rules Regarding Secondary Diagnoses
Secondary diagnoses require at least one of the following:
Clinical evaluation Therapeutic treatment Diagnostic procedures Extends length of hospital stay Increased nursing care and/or monitoring
Probable, Possible, Suspected, and Unable to Rule Out
In the inpatient setting you may use the Probably, Possible, Suspected and unable to Rule Out.
If the condition is Ruled Out then state such and it will not be coded.
Our Goal
Accuracy
Accurate documentation appropriately reflects the severity of illness of our
patients and the most accurate risk of mortality.
Medicare Changes- “POA”
• Present on Admission = POA– To better measure hospital performance
(good and bad)– To increase validity of hospital report cards
related to quality– Distinguish between pre-existing conditions
and hospital acquired conditions ($$)
Identified Conditions
• Decubitus Ulcers• Catheter Associated UTIs• Vascular Catheter Associated Infections• Falls, Burns – Trauma while inpatient• Mediastinitis that Follows Heart Surgery• Object Left in Surgery• Air Embolism• Blood Incompatibility
Potential Implications to UMHC
• Our public image
• Financial
Patient: Granny SmithMedicare DRG
66 Intracranial Hemorrhage or Cerebral Infarction w/o CC/MCC
CMS Wt: 1.0303 ALOS 3.8 GLOS 3.1
Principal Diagnosis
43491Unspecified cerebral artery occlusion with cerebral infarction
Secondary Diagnoses
27651 Dehydration
4019 Essential hypertension
78097 Altered Mental Status
2449 Hypothyroidism
2724 Hyperlipidemia
Estimated Payment:
$8,192.65
Granny SmithMedicare DRG
65 Intracranial Hemorrhage or Cerebral Infarction w CC
CMS Wt: 1.1901 ALOS 5.3 GLOS 4.3
Principal Diagnosis
43491 Unspecified cerebral artery occlusion with cerebral infarction
Secondary Diagnoses 99664 Infection / inflammation due to indwelling urinary catheter
27651 Dehydration
4019 Essential hypertension
78097 Altered Mental Status
2449 Hypothyroidism
2724 Hyperlipidemia
5990 Urinary tract infection
Principal Procedure
5794 Insertion of indwelling urinary catheter
Estimated Payment:
$9,463.34
What does this mean?
• Last year if the patient developed a UTI post catheter placement we were paid $9463.34
• NOW, we are not reimbursed the additional $1,270.69
Granny has surgery
Medicare DRG 470 Major Joint Replacement w/o MCC
CMS Wt: 1.9871 ALOS 4.0 GLOS 3.7 Principal DX 996.43 Prosthetic joint implant failure Secondary DX 599 Urinary tract infection 780.97 Altered mental status 401.9 HTN 244.9 Hypothyroidism Principal Procedure 81.52 Partial hip replacement Estimated Payment: $15,800.85
Granny has surgeryMedicare DRG 469 Major Joint Replacement w MCC
CMS Wt: 2.6664 ALOS 8.4 GLOS 7.1 Principal DX 996.43 Prosthetic joint implant failure
Secondary DX 707.03 Decubitus ulcer, lower back 599.0 Urinary tract infection 780.97 Altered mental status 401.9 HTN 244.9 Hypothyroidism Principal Procedure 81.52 Partial hip replacement Estimated Payment: $21,202.45
What does this mean?
• Last year if the patient developed a decubitus while hospitalized we were paid $21,202.45
• Now, we are not reimbursed the additional $5,401.60
What can you do?
Complete initial admission assessments to include visual inspection of the skin
Document all findings in the medical record
Remember possible, probable and suspected are ok to use in the inpatient setting
Wash your hands
Follow all protocols for dressing changes, IV line insertions and care, foley cath insertions and care
National Patient Safety Goals
• Identify patients correctly• Improve staff communication• Use medications safely• Prevent infection• Accurately reconcile medications across the
continuum of care• Prevent patients from falling• Help patients to be involved in their care• Identify patient safety risks• Improve recognition and response to changes in
patient’s condition• Prevent errors in surgery
Hospital Compare - A quality tool for adults, including people with Medicare
Find and Compare HospitalsWelcome to Hospital Compare. This tool provides you with information on how well the hospitals care for all their adult patients with certain conditions or procedures. This information will help you compare the quality of care hospitals provide. Talk to your doctor about this information to help you, your family and your friends make your best hospital care decisions.
Hospital Compare was created through the efforts of the Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services, and other members of the Hospital Quality Alliance: Improving Care Through Information (HQA). The information on this website has been provided primarily by hospitals that have agreed to submit quality information for Hospital Compare to make public.
Hospital Process of Care Measure
UNITED STATES
AVERAGE
MISSISSIPPI AVERAGE
Percentage for UNIVERSITY OF MISSISSIPPI MED CENTER
Percent of Surgery Patients Who Received Preventative Antibiotic(s) One Hour Before Incision if appropriate*
82% 77%83% of 718 patients2
Percent of Surgery Patients Who Received the Appropriate Preventative Antibiotic(s) for Their Surgery if appropriate*
90% 83%96% of 729 patients2
Percent of Surgery Patients Whose Preventative Antibiotic(s) are Stopped Within 24 hours After Surgery if appropriate*
78% 74%86% of 696 patients2
Percent of Surgery Patients Whose Doctors Ordered Treatments to Prevent Blood Clots (Venous Thromboembolism) For Certain Types of Surgeries if appropriate*
79% 70%88% of 345 patients2
Percent of Surgery Patients Who Received Treatment To Prevent Blood Clots Within 24 Hours Before or After Selected Surgeries to Prevent Blood Clots if appropriate*
75% 66%83% of 345 patients2
University Hospital Consortium (UHC) Benchmarking:• Similar to CMS reporting, but a broader
range of measures• Compares us to other Academic Medical
Centers• We are making progress, but many
opportunities for performance improvement
JCAHO REQUIREMENTS
• Federally identified OPO• Procedures in place for notifying OPO in
a “timely manner” of deaths and/or impending deaths
• Procedures in place for notifying family of donation option by trained requestor
• Written documentation of consent or decline
• Hospital works with OPO to educate staff on donation issues
• 2005 “Conversion Rates” Focus----75%!!!
Organ Donation at UMHC• 2006 conversion 34%• 2007 conversion 63%• 2008 conversion 72%• To date 2009 conversion rate 53%
• Active “Donation after Cardiac Death” protocols• Brain Death declaration check sheets available• Potential Donor management protocols available
The Potential Organ Donor
Absolute Exclusions
• Active UNTREATABLE infection• CURRENT malignancy
(Specific ORGAN failure may rule out organ but NOT donor!)
Consent for Organ Donation
• Federal regulations mandate ONLY “trained requestors” approach families for donation consent
• Minimal acceptable “training” 8 hours• Numerous variables are felt to impact
families likelihood to donate• Consent is a PROCESS not a
QUESTION!
What YOU Can Do…
• Learn the FACTS about organ donation• Decide your personal donor status• Tell your family and friends about your
donation wishes• Look for opportunities to help others learn
about donation• Talk to your patients about donation in
advanced directive discussions• ALWAYS follow hospital and federal
regulations regarding offering families donation option