Guest Post: What is All This Fuss about Quality?
by Karen Newhouser, RN, BSN, CCDS, CCS, CCM
Quality. If we had a dollar every time that word is used, we would be wealthy. But money isn’t everything. Just consider the evolution of the CDI profession.
True, the CDI profession was built on a financial platform – it’s how CDI programs got in the door in the early years. Now, the focus in healthcare is quality. Quality is the common theme in many healthcare initiatives. It may seem that quality just surfaced, but it has been on the scene for decades.
Pay-for-performance (P4P) is the umbrella from which all modern-day quality indicators stem since its emergence in the early 2000s—after deficiencies in quality were highlighted on two major reports by the Institute of Medicine, To Err is Human: Building a Safer Health System, in November, 1999, and Crossing the Quality Chasm—A New Health System for the 21st Century, in March, 2001. These reports recommended a sweeping redesign of the health care system to improve quality of care.
In this context, P4P emerged as a way for payers to focus on quality, with the expectation that doing so will also reduce costs. The typical P4P program provides a bonus to health care providers if they meet or exceed agreed-upon quality or performance measures. P4P programs can also impose financial penalties on providers that fail to achieve specified goals or cost savings.
P4P programs can be broken down into both private sector and public sector initiatives. The largest and longest running (2001) is the California’s program. Within the public sector, CMS established a Value-Based Purchasing (VBP) program to provide incentives for physicians and providers to improve the quality and efficiency of care. Most of these programs focused on quality with little, if any, cost consideration.
P4P evolved and grew and the Affordable Care Act further encouraged improvements in quality of care while addressing the subject of cost. Due to CMS’ continuous updates in its IPPS proposed and final rules, a few of the P4P programs worth paying attention to include:
- Hospital Value Based Purchasing Program
- Hospital Readmission Reduction Program
- Hospital Acquired Condition (HAC) Reduction Program
As with most quality measures, establishing present on admission (POA) status is crucial. If one looks at POA with a widely general view, if the patient did not come into the hospital with a particular condition, then they acquired it in the hospital. One element to remember is that POA is not limited to a “Y” (Yes) or “N” (No) determination; a provider may also state that he or she is unsure/unable to determine/doesn’t know if the diagnosis was POA. This POA indicator of “W” is considered to be equivalent to an indicator of “Y” and will exempt the condition from being identified as a HAC.
Similarly, a fourth indicator of “U,” or the documentation is insufficient to determine if the condition was present at the time of inpatient admission, is equivalent to an indicator of “N” in a POA determination where a HAC is identified. It is important to note the words “documentation is insufficient…” in the above indicator explanation. These words should be an indication that a query is warranted in an attempt to obtain sufficient documentation to make a POA determination.
The most important point to understand about these initiatives is that they are risk-adjusted. Reporting agencies have their own risk-adjusted methodologies and most are proprietary; it is not necessary to know the methodology. What is relevant is these methodologies use factors such as chronic and co-morbid conditions to determine the degree of risk. The greater the number of, and/or the more significant, the chronic and co-morbid conditions, the higher the risk.
We all realize that the patient entering the hospital today is much sicker than the patient entering the hospital 20 years ago. That is the role of the CDI specialist—to ensure that the record identifies an appropriate principal diagnosis and reflects all significant reportable secondary conditions to match the care delivered and resources consumed.
We are charged with carrying forward the story of the patients’ encounter. We are, in essence, the editors of a non-fiction story. As we move towards a personal health record in our mobile age, it is imperative that we advocate for the patient and appeal for a complete, accurate account of their health status.
Yes, this is the fuss about quality. Our patients are depending on us. We won’t let them down.
And while it isn’t all about money, I would be remiss in not recognizing the role that money plays in all of the above; however, I leave you with this thought…
Quality doesn’t follow money; money follows quality.
Editor’s note: Newhouser, at the time of this article's original release, was the director of CDI education for MedPartners CDI in Tampa, Florida, and the 2015 winner of the CDI Professional of the Year award. This article originally appeared in the CDI Horizons newsletter.