The Changing Role of The Changing Role of DocumentationDocumentation

October 18, 2007October 18, 2007

Today’s Topic Today’s Topic

The way it used to be The way it used to be

The way it is nowThe way it is nowPatient safetyPatient safety

Performance improvement through public Performance improvement through public reportingreporting

CMS annual payment updateCMS annual payment update

Patient care satisfactionPatient care satisfaction

Reliable Documentation Reliable Documentation

An 80 or 90 percent success rate might sound good to an institution, but An 80 or 90 percent success rate might sound good to an institution, but from the patient’s standpoint it’s unacceptable, says Resar. “A hospital from the patient’s standpoint it’s unacceptable, says Resar. “A hospital wants to know how well it’s doing for its entire patient population. The wants to know how well it’s doing for its entire patient population. The patient wants to know how well you’re doing by him or her.” For the patient wants to know how well you’re doing by him or her.” For the individual patient, reliability is an “all-or-none” matter, says Resar. “If individual patient, reliability is an “all-or-none” matter, says Resar. “If the right care has five elements and the medical team accomplishes all the right care has five elements and the medical team accomplishes all five only 90 percent of the time, that’s 100 percent failure for each of the five only 90 percent of the time, that’s 100 percent failure for each of the 10 percent of patients who don’t get all the recommended care. There is 10 percent of patients who don’t get all the recommended care. There is no partial credit for reliability.” (For a recent discussion of “All-or-None no partial credit for reliability.” (For a recent discussion of “All-or-None Measurement," see the March 2006 article by Berwick and Nolan.) Of Measurement," see the March 2006 article by Berwick and Nolan.) Of course, even when human beings do their very best, they don’t always course, even when human beings do their very best, they don’t always succeed, so Resar and other faculty leading an IHI Learning and  succeed, so Resar and other faculty leading an IHI Learning and  Innovation Community have developed a framework for improved Innovation Community have developed a framework for improved reliability based on industrial principles of standardization. It begins with reliability based on industrial principles of standardization. It begins with protocols of care that are evidence-based and widely agreed-upon, says protocols of care that are evidence-based and widely agreed-upon, says Fran Griffin, RRT, MPA, who is the Director for Designing for Fran Griffin, RRT, MPA, who is the Director for Designing for Reliability in Clinical Practices as part of IHI’s IMPACT Program.Reliability in Clinical Practices as part of IHI’s IMPACT Program.

Today’s Goals & Objectives Today’s Goals & Objectives

Insight from best practice hospitals Insight from best practice hospitals

ObjectivesObjectivesLearn about successful documentation Learn about successful documentation processesprocesses

Understand how to address gaps in the Understand how to address gaps in the documentation processdocumentation process

Take away practical ideas for change Take away practical ideas for change

Process Flowchart Process Flowchart Hx CHF

Adm

Dx Acute CHF

Rx CHF

Discharge

Death

Coding

CHF Standing Order Sets & Care Patways

Documentation ProcessDocumentation Process

Panel of 3 hospitals tell their story Panel of 3 hospitals tell their story Panel discussion of their process to assure Panel discussion of their process to assure reliable documentationreliable documentation

What steps are used consistently to provide What steps are used consistently to provide accurate and reliable documentationaccurate and reliable documentation

What tools secure the documentation is in What tools secure the documentation is in the chartthe chart

Documentation ProcessDocumentation Process

How they handle variations in How they handle variations in documentationdocumentation

How they got everyone (physicians, nurses, How they got everyone (physicians, nurses, ancillary support staff) singing the same ancillary support staff) singing the same tunetune

Why team work is essentialWhy team work is essential

Questions Questions

One problem that we face is working with One problem that we face is working with physicians on improving their physicians on improving their documentation. How can we encourage documentation. How can we encourage them to be more helpful? Any ideas?them to be more helpful? Any ideas?

QuestionsQuestions

We do computerized documentation using We do computerized documentation using flowcharts and electronic forms. We have flowcharts and electronic forms. We have piloted "Charting by Exception" in our piloted "Charting by Exception" in our obstetrical area. We would like one of the obstetrical area. We would like one of the discussions to be on "Charting by discussions to be on "Charting by Exceptions". We did contact JCAHO and Exceptions". We did contact JCAHO and they said that it can be used. My thoughts they said that it can be used. My thoughts only.only.

To ConsiderTo Consider

Does the chart forms and format reflect the Does the chart forms and format reflect the core measurement requirements?core measurement requirements?

Do the physicians understand why Do the physicians understand why documentation and the core measures documentation and the core measures reflect the evidence-based guidelines? reflect the evidence-based guidelines?

Does the abstraction staff understand the Does the abstraction staff understand the complete definitions of all data elements for complete definitions of all data elements for the core performance measures?the core performance measures?

Contact Information:Contact Information:

MetaStar, Inc.MetaStar, Inc.2909 Landmark Place2909 Landmark PlaceMadison, WI 53713Madison, WI 53713

(608) 274-1940 (608) 274-1940

www.metastar.comwww.metastar.com

This material was prepared by MetaStar, the Medicare Quality Improvement Organization for Wisconsin, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-WI-INP-07-144.