thequalitypost Greetings from Michelle, Nader and Sasha

QUALITY IMPROVEMENT DIVISION OF HOSPITAL MEDICINE Welcome to the 46th edition of The Quality Post. In this issue we feature tips for SHM Abstracts and feature a piece on Clinical Documentation Improvement. We also bring you an attending guide for the “4+1” campaign and data on our Division Incentive Metrics.

Top Tips Abstract Creation

Fall has just begun, but it’s already time to start thinking about your abstract submissions for meeting season this year! The SHM submission deadline is December 10. Sign up for a

spot at Incubator, DHM’s Works-in-Progress sessions, and consider these tips: General tips for both research and innovations: Does it have a catchy title? Does the abstract meet the character limit? Is this better suited for a research or innovations abstract?

Innovations: New project or care delivery model, already implemented with preliminary results. The goal is to allow the reader to recreate your project Research: Completed project with results. The goal is to disseminate the results that would change current practice

Use a consistent tense, generally the past tense, even for ongoing projects If submitting to SHM, how does this apply to the “hospitalist” audience?

Research

Background: Is the background three sentences or less? Confine your background to the

essential lead in. Avoid generic statements like “Communication is important in the hospital setting” as this will use unnecessary words.

Methods: Do you describe the setting of the study, your inclusion/exclusion criteria, and

your primary and secondary outcome measures? Do you include numbers where possible (number of residents in the program,

patients on the service, attendings on service) to give a sense of scope? Do you include details on how the results were collected (e.g. surveys, automating

reports from EMR, chart review by 2 independent reviewers)? If it is a qualitative study, do the methods use appropriate language (buzz words)

to add rigor to your method of analysis (convenience sample, observation protocols, hypothesis testing, grounded theory, content analysis)?

Inclusion of the statistical tests used can be included or omitted based on work count but are less essential for an abstract.

Results: Would a table or figure be helpful in synthesizing and representing your results? Did you reference the figure in the text rather than restating the findings? Are there tests of statistical significance you could do? Do you include the n along with your percentages (in the text, tables, and

figures)? Conclusions (Do not use phrases such as “The results will be discussed”). Does your first line summarize the most interesting/noteworthy results for your

reader?

in this issue

Monthly Quality Improvement Newsletter for the Division of Hospital Medicine

October 2014 Issue 46

Tips for Abstract Creation

Clinical Documentation Improvement

4+1 Attending Guide

Division Incentive Metrics

Top Tips for SHM Abstract Creation Continued…

Innovations

Background Is the background three sentences or less? Confine your

background to the essential lead in. Avoid generic statements like “Communication is important in the hospital setting” as this will be obvious to the reader and use unnecessary words.

Purpose Try and keep this to a single line. A complete sentence is not

necessary. “To improve physician introductions including name and role through the use of individual facecards.”

Description Was a needs assessment done for your intervention? Include one to two lines to support why your

innovation is needed. If someone wanted to reproduce your study could they do so reading your description? Do you include

details of any process for idea generation, stakeholder engagement, pilots, etc? Have you included preliminary results from your innovation? (for your innovation to be credible you must

include preliminary results, even if it is preliminary survey of attitudes and adoption, a focus group, or scope of your implementation).

Conclusions How do the preliminary results of the innovation suggest that it will succeed in achieving (or failed to

achieve) your desired objective? What next steps will be needed in determining scope, implementation or value of your innovation?

Clinical Vignettes The goal of a Clinical Vignette is to gently lead the readers to the eventual diagnosis while teaching them key clinical pearls about the disease or its presentation. It is helpful to have an “organizational theme” which could be: highlighting an atypical presentation to a typical disease, identifying a commonly missed diagnosis due to a disease mimicker, describing a classic presentation of a rare disease. Stay away from a rare presentation of a rare disease! This will have little value for the audience and for the judges. New emerging themes: describing an example of over use of resources and unnecessary testing that should be avoided and that may lead to adverse outcomes, describing a challenging ethical situation and how it was navigated and discussed by ethicists.

A catchy title is a must! Do you give your readers a clue to figuring out the case, but don’t give it away Case Presentation Do you provide only the salient details (pertinent +/-) of history,

physical and labs? (i.e. do not include all PMH or labs if they do not have a utility in the case.

Do you provide enough clues to the diagnosis and to potential red herring diagnoses to lead your reader to the answer?

Is there a dramatic turn in the case around the revelation of the correct diagnosis? Create as much of a cliffhanger as possible for your readers.

Discussion How does this case illustrate your key clinical pearl for your readers?

Pick 2-3 “pearls” for your readers. Conclusions How should readers (specifically hospitalists - if this is your audience) apply

this knowledge to their clinical practice?

Clinical Documentation Improvement

How is Severity of Illness measured?

Severity of Illness is based on the Case Mix Index (CMI) of your patient population.

The CMI is used to Risk Adjust patient outcomes and costs of care.

Every Medicare principle diagnosis or MS-DRG is associated with a case mix index.

Complications and Comorbidities AND

Major Complications and Comorbidities

.

MS-DRG CMI LOS

446 Disorders of Biliary Tract w/o CC or MCC 0.7 2.4

Secondary Diagnosis- leukocytosis

445 Disorders of Biliary Tract w CC 1.0 3.5

Secondary Diagnosis- bacteremia or cholangitis

444 Disorders of Biliary Tract w MCC 1.6 4.7

Secondary Diagnosis- Severe sepsis

GOALS OF THE PROGRAM: • Document, capture and code all diagnoses, procedures, co-morbidities and complications • Accurately and completely reflect the clinical complexity of our patients and the quality

of their care • Improve publically reported measures and ratings

What is the relationship between our quality outcomes and how we document?

Hospitals are increasingly being judged on our quality outcomes-- outcomes like mortality, LOS, and hospital acquired complications; all of which are adjusted by patient’s severity of illness.

Capturing severity of illness thus becomes increasingly important if we want our quality measurements to be accurate measures of our performance as physicians and as a medical center.

Related diagnosis groups of

44X differ in the

presence or lack of CC’s

or MCC’s.

Add to the principle diagnosis or the DRG to increase the Case Mix Index and expected LOS of patients.

Documenting “Leukocytosis” will result in severely under representing this patient’s severity of illness.

If we want our quality outcomes and LOS to be judged fairly we need to pay attention to how we document co-morbidities and complications

Clinical Documentation Improvement Attention to just some simple specific terms can eliminate the need for most queries!

Other more unique issues to be aware of:

The old way The new way

CKD CKD and the stage

Volume overload Echo shows low EF HFpEF or HFrEF

Acute pulmonary edema Acute/Chronic systolic heart failure Acute/Chronic diastolic heart failure

Vent dependent Unable to wean from vent

Acute hypoxemic respiratory failure

Requiring pressors Septic/Cardiogenic Shock

Rising Creatinine AKI/ ATN (remember contrast nephropathy is ATN

GI bleed Acute anemia 2/2 Blood Loss

AMS Encephalopathy or Coma

SIRS & SEPSIS

Look for SIRS with every infection o SIRS + Infection = Sepsis

Look for organ dysfunction and document Severe Sepsis

Document Sepsis in the discharge summary (let’s the coders know this was a confirmed Dx)

SIRS without an infection is still a marker of

severity (Think of a severe COPD patient)

HEALTH CARE ASSOCIATED PNA

Not all PNA are created equal Health care associated PNAs carry a higher

risk of readmission Unfortunately documenting HCAP is not

enough! Document broad spectrum antibiotics and

the organisms the are covering for HCAP: Treating with Zosyn for possible pseusomonas and vancomycin for possible MRSA

NSTEMI TYPE II vs. DEMAND ISCHEMIA

The problem: We use these terms interchangeably, but they are different codes!

In the coding world: NSTEMI = Acute MI

To be accurate use:

NSTEMI Type II for TROPONIN + EKG changes, Typical Symptoms or wall motion abnormalities

Demand Ischemia for isolated Troponin Elevation in the setting of non-cardiac disease

ENCEPHALOPATHY

What is encephalopathy? A global or diffuse alteration in brain function associated with a systemic cause. Examples: Toxic – intoxication/withdrawal or over

medication Infectious – AMS from sepsis Hepatic – Excess ammonia Ischemic – Associated with stroke or shock

Urosepsis Pneumosepsis Biliary Sepsis

Division Incentive Metric Performance

Decrease number of total phlebotomy draws by from 2.05 to 1.9 sticks (7.3%) per hospitalized patient per day  FY 2014 Baseline 

3 of 12 months 2.05 sticks per patient day 

July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June 1.96 2.02 1.97

Decrease total telemetry hours / DHM admissions from 35 hours to 30 hours (15%) 

FY 2014 Baseline   

6 of 12 months 35 hours 

July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June 24 32.5 28.8

Achieve HCAHPS Communication with Doctors Top Box score above 80%  FY 2014 Baseline 

6 of 12 months 74.6% 

July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June 76.7%

Achieve 20% of patients discharged by noon   

FY 2014 Baseline 6 of 12 months 

15.7% 

July Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun 14.8% 20.2% 20.7%

Increase rates of 14‐day PCP follow‐up appointments scheduled, with appointments scheduled by 5 days after discharge, to 80% 

FY 2014 Baseline 

 

3 of 12 months 68% 

July Aug Sept Oct Nov Dec Jan Feb Mar April May June 72.4% 77.1%