Q&A: Expanding into quality reviews
Editor’s Note: As part of the fifth annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Mary Kay Brooks, RN, MSN, CPHQ, the director of CDI at the University of Iowa Hospitals & Clinics, in Iowa City, answered the following questions regarding CDI expansion into quality reviews specifically regarding the improvement of her facility’s capture of patient safety indicators. Contact her at mary-brooks@uiowa.edu.
Q: What was the impetuous for shifting your CDI program alignment under the chief medical officer (CMO)?
A: Shifting the program helped to signify the importance of CDI to our physicians and physician extenders. CDI-related metrics are included in our provider performance evaluation data.
Q: Is there any dotted line alignment of the CDI program with quality or HIM?
A: Not officially. I ran the quality/safety department for eight years, so I was already very familiar with the publicly reported quality/safety metrics, and had a solid working relationship with HIM. We definitely closely team with HIM.
Q: Can you provide a brief scenario/description of what PSIs are and why documentation failures might affect this reporting?
A: PSIs are a set of risk‐adjusted metrics for adult and pediatric patients that identify potential hospital complications or adverse events after surgery, procedures, and childbirth. They’re used to evaluate and/or reward hospital or physician performance.
Q: Why did you focus on PSI 15 and 90?
A: We focused on the metrics that had the biggest impact (particularly related to Medicare’s value based purchasing initiative) and opportunity for improvement. PSI 15 is for accidental puncture and laceration (APL) rate.
We realized that there was no consensus between physician documentation and coding guidelines for certain types of injuries and that those situations where the condition was inherent, intended, or routinely expected were being coded as APL, which in turn led to a complication report. So we focused on educating physicians about APL to increase their awareness of the metric and how it is being used.
Then we asked the physicians for assistance and cooperation during reviews. Additionally, we establish a feedback mechanism so we can show them when their data improved and they share with us any problems or difficulties they have.
The PSI 90 is a composite metric and includes:
- PSI 03 – Pressure Ulcer Rate
- PSI 06 – Iatrogenic Pneumothorax
- PSI 07 – CVC‐Related Bloodstream Infection
- PSI 08 – Postoperative Hip Fracture
- PSI 09 – Postoperative Hemorrhage or Hematoma
- PSI 10 – Postoperative Physiological and Metabolic Derangement
- PSI 11 – Postoperative Respiratory Failure
- PSI 12 – Postoperative Pulmonary Embolism or Deep Vein Thrombosis
- PSI 13 – Postoperative Sepsis Rate
- PSI 14 – Postoperative Wound Dehiscence
- PSI 15 – Accidental Puncture or Laceration Rate
Q: What was the biggest challenge you faced as you expanded your CDI program’s focus?
A: Educating the CDI nurses on the quality metrics specifications and finding the balance of accurately identifying and coding true complications.
Q: What “ah-ha” moments did the CDI team realized as they began their record reviews?
A: I would say learning to look beyond what simply impacts the quality scores versus what should truly be considered a complication.
Q: What tracking/monitoring data did you use and how often did you review that information?
A: We have an audit set up with HIM to target cases of interest. We look at information retrospectively/comparatively through Hospital Compare and University HealthSystem Consortium data.
Q: What other quality measures/areas might your facility look at investigating?
A: We are primarily targeting hospital acquired conditions and PSIs for adult and pediatrics.
Q: Is there a danger that CDI programs focus on a topic, switch focus and then lose ground they previously gained? (So, if you made progress on PSI 15/90 and move onto HAC focus will physicians go back to their previous poor documentation ways?)
A: Not so far. We routinely monitor or performance, and conduct mini reviews to identify failures.
Q: What staffing considerations should CDI programs evaluate prior to expanding review efforts?
A: Well, certainly your program should be fully staffed. You should also identify some early physician CDI adopters to enlist as “helpers” and “educators” for your physicians and targeted staff.
Q: What advice would you offer to CDI programs/staff looking to possibly expand their reviews?
A: Pick one or two metrics to start with. Don’t go overboard.