Subject:                          Quest June.html


This message is sent on behalf of Chief Medical Officer Theresa Brennan, MD


Monthly Patient Safety, Quality, and Service Excellence updates from the Chief Medical Officer


Quality updates

Clinical Documentation Improvements

·         The Clinical Documentation Handbook is now available. This is a resource to improve documentation, which ensures: 1) capture of the full complexity of our patient population; 2) quality and safety data that reduces compliance risk and poor outcome reporting; and 3) assures reimbursement is not at risk for a death rate that exceeds Risk of Mortality (ROM) data. Read more.

·         Get ready for ICD-10 starting now! Accurate ICD-10 coding will require specific and accurate documentation by all providers.  It is important to maintain our Severity of Illness (SOI) and Risk of Mortality (ROM) statistics by learning what is required to achieve accurate ICD-10 coding for both inpatients and outpatients. For a copy of the short reference developed for LIPs, contact Mary Kay Brooks at 384-8206 or

·         Do not resuscitate (DNR) status significantly impacts patient risk adjustment. DNR status is captured via ICD-9 code V49.86 (ICD-10: V66). Hospital coders need the LIP to document the current DNR status in their H&P and/or progress notes for this condition to be assigned an ICD-9 code. Hospital coders cannot use the code information listed in the patient header line in Epic.

Patient safety updates

New pharmacy system

UI Health Care Outpatient Pharmacies have converted to a new pharmacy computer system, Epic Willow Ambulatory, as of June 13. The new system is integrated with Epic and allows patients to request refills and renewals through MyChart. Care providers can see when the last refill occurred and how many refills remain. Read more.


Hand hygiene update

Hand hygiene adherence data, June 7 to 13


Office of The Patient Experience

June’s newsletter:


The Beryl Institute memberships

UI Hospitals and Clinics has purchased an institutional membership to The Beryl Institute, the leader on improving the patient experience in health care. Membership includes access to resources and training on patient experience, and discounts on training and networking events. Read more.


3P Lean: People, Preparation, Process

The new Pain Medicine Clinic opened in January and is one of the first projects at UI Hospitals and Clinics designed using Lean design concepts and 3P (People, Preparation, Process) planning. The technique prospectively eliminates waste throughout the project and process by designing the process first before focusing on the layout to support the process. Read more and see photos.

Staff Engagement/Safety Culture Survey 2015

Press-Ganey has sent out emails with a personalized link to the survey. This is not spam and is confidential. Check your inbox and junk email folders. Tell us what you think. Your opinion counts! For survey support or to request another survey, email the Press-Ganey support at See response rates, updated daily.