Our Stories: Vizient quality and accountability scorecard

Hospital quality metrics are a set of standards developed by the Centers for Medicare & Medicaid Services (CMS) to quantify health care processes, patient outcomes, and organizational structures. You are likely familiar with some of these key metrics such as length of stay, 30-day readmission rates, or mortality rates which may be reviewed at a clinical service line, department, or hospital-wide level.

Hospital-acquired conditions such as central line-associated blood stream infections (CLABSI), catheter-associated urinary tract infection (CAUTI), or surgical site infections (SSIs) are also key quality metrics for a health care organization to track and monitor because preventing these from occurring in our patients is central to the goal of ensuring that every patient receives safe, effective, and high-quality care that is free of all preventable harm. 

CMS spearheads dozens of initiatives with publicly reported data aimed at reducing overall health care costs and improving care quality, including programs such as the Hospital Outpatient Quality Reporting Program, the Hospital Inpatient Quality Reporting Program, the Hospital Value-Based Purchasing Program, and the Hospital-Acquired Condition Reduction Program. 

Although the focus and metrics differ among these programs, the underlying premise of performance measurement and improvement is something that we can certainly all support. 

Derek Zhorne, MD, Interim Chief Quality Officer

The Vizient Quality and Accountability scorecard is a tool that measures academic medical centers (AMCs) clinical performance year over year focusing on quality and safety in comparison with similar hospitals while targeting specific opportunities for improvement. The Q&A provides scoring and ranking across the cohort group of AMCs to identify structures and best practices across a variety of patient populations divided into six weighted domains. 

Vizient also provides a quarterly calculator reports with the same metrics within the six domains and allows quarterly ranking to track progress throughout the year. Within the calculator, a member can perform “what if” analyses to identify projected rankings and how scores with improved metrics will impact rankings.

CMS have developed a methodology to calculate and display overall hospital-level quality using a Star Rating system. An individual hospital is assigned a summary Star Rating of between 1 to 5 stars (more is better) based on the hospital’s performance across a variety of quality measures. The most recent CMS Star Rating included forty-nine individual quality measures among the five measure groups of mortality, readmission, safety of care, patient experience, and timely and effective care. The intent of the CMS Star Rating is to improve the usability and interpretability of information posted on Care Compare, which is a website designed for consumers to use along with their health care provider to make decisions on where to receive care. The CMS Star Rating is usually updated each year.

  • What are these data sources?
    • Data sources for the Vizient Q&A scorecard is provided at the encounter level that we submit monthly to Vizient. It is based on our EPIC billing data.
    • CMS gets the data from two sources: 1) claims submitted to CMS for delivered care; and 2) information collected from patient medical records.
  • How is the data for each collected?
    • UI Hospitals & Clinics submits encounter level data to Vizient monthly by using an extraction process from Clarity (EPICs data warehouse). The extraction process from Clarity begins as soon as the previous completed month reaches at least 90% “Coded Complete” in EPIC. We submit both Inpatient and Outpatient encounters in our Clinical data submission files. We utilize a rolling three-month period with every monthly submission to Vizient so we have the opportunity to pick up any late coded, changes, edits, etc. from a specific month, three different times. We also resubmit every fiscal year to catch any late changes prior to the deadline for the annual Q&A scorecard.
    • In general, the CMS rating is calculated through a complex process of grouping measures, calculating group scores, weighting summary scores, and dividing hospitals into appropriate peer groups for comparison purposes. The details of the methodology have changed over time.
  • Where does the scorecard live?
    • Our Vizient Q&A data and scorecard lives within the Vizient Clinical Database. Vizient also offers an online query tool to run routine and ad hoc reports to track performance throughout the year. Our analytics team downloads encounter level data from the Clinical Database and stores the data both in HEDI Data warehouse as well as on Tableau Server for end users to easily access.

  • Who manages the data?
    • Currently HCIS, and Hospital Decision Support manage the Vizient data. The CMO office manages the Q&A scorecard as well as providing analysis and presentation of the scorecard. The analysts in the CMO office are also responsible for validating and overseeing the entire cycle from data submission to extraction of the data.  
    • The Quality Improvement Program (QuIP) manages the evaluation and submission of the CMS quality measures. A team in Health Information Management collaborates with QuIP to abstract the data from the medical records according to measure specifications. Both teams leverage subject matter experts to improve performance on the measures and validate the data prior to submission.
  • Why are these important in terms of quality work and how they directly affect the hospital?
    • The Q&A is important to see how well we are providing quality and patient safety to our patients. The metrics within the Q&A look at hospital acquired conditions as well as clinical metrics such as mortality, length of stay, and direct cost. When compared against other academic medical centers, we can identify where we have the largest opportunities to become better performers, whether it be in documentation, coding, or processes. It also is important as it gives us an idea on how satisfied our patients are with their care and where we can improve satisfaction across the institution.
    • The CMS Star Rating is publicly available on CMS’s Care Compare website along with UI Hospitals & Clinic’s performance on each quality measure. The quality measures within the CMS Star Rating are also included in CMS’s Pay-for-Performance Programs.
  • What are the similarities and differences/variations in these data sources?
    • Similarities: Both use our hospital encounters to identify our performance across quality, safety, and patient satisfaction.
    • Differences: Vizient utilizes all inpatient and outpatient payors, including Medicare, Medicaid, and private insurances. Vizient also looks at all patients ages. CMS Star Rating only looks at Medicare Payors and patients 65 and older.
  • How do they overlap?
    • Many of the metrics within the two reports are the same in regards to quality and safety.
  • Why you might see that we are ranked high in one versus the other?
    • The Q&A only uses comprehensive academic medical centers. All patient ages and all insurance payors. The category/domains are weighted differently.
  • What about the difference in time frames?
    • CMS Star Rating looks at older data when its calculating rankings, currently the Star Rating is based on fiscal year 2017 to fiscal year 2019 data. Vizient annual scorecard includes the previous fiscal year performance released in the fall of each year, currently July 2020 to June 2021.
  • How do individuals access the data?
    • The Vizient Q&A is available to view and download directly from the Vizient Clinical Database site. Regarding our internal reports, the majority of the Vizient data and reports are available on Tableau Server.
  • Who to work with to better understand the data:
    • Vizient Benchmarking:
      Kelly Noel-Roszell, Quality and Operational Improvement Engineer, Vizient Analyst, Vizient CDB Coordinator

Kelly Noel-Roszell
Quality and Operational Improvement Engineer, Vizient Data Analyst, Vizient CDB Coordinator

Jennifer McDanel
Quality & Operations Improvement Engineer

Our Stories: Delta is different, our goals are the same

If you’ve been following the news or watching the COVID-19 numbers reported in Noon News, you’ve likely seen a noticeable difference in the status of the pandemic in the U.S. as compared to just a month ago. Unfortunately, the evolution of the pandemic is not trending in a positive direction. However, there is still positive news to share.  

We’re equipped with the resources we need to focus on safety.  

COVID-19 vaccinations 

If you haven’t yet received your COVID-19 vaccine, it’s as easy as a call to our Employee Health Clinic at 319-356-3631 to ask your questions and get your vaccination scheduled. 

Wondering how to encourage your patients, family members, or friends to get vaccinated? 

  • According to the Kaiser Family Foundation, eight in 10 people look to their health care providers when deciding whether to receive the COVID-19 vaccination. Check out our guide for addressing vaccine hesitancy with your patients. 
  • Did you know we have fact-based vaccine information you can share with family and friends? View more at uihc.org/covid-vaccine

Safety resources 

  • As a reminder, you can find our own safety guidelines, tips, and information on The Loop.  
  • Pediatric resources are available on uichildrens.org. This includes tips for helping remind kids to wash their hands, a Q&A video with pediatrician Hao Tran, MD, on keeping kids safe as they return to school, among many other resources for families. 
  • Looking for general safety resources? Our COVID-19 hub on uihc.org has information about COVID-19 testing for patients, what to do if someone in your home is sick, and more. 

The delta variant, which is now causing the vast majority of COVID-19 cases in the U.S., is fundamentally different than the earlier versions of the virus. It spreads more easily, but the way out of this pandemic is the same. We work together, we stick to what we know works when times are tough, and we share the word about how we can all do a little to make a big difference.  

Thank you for all that you do, seen and unseen, each and every day. 

—Theresa Brennan, MD, Chief Medical Officer

Our Stories: The future may be foggy, but our path forward is clear

I want to start by saying how proud I am of our faculty, staff, and trainees and their response to this pandemic so far. A vaccination rate of 90% is a great accomplishment for any organization! I wish we were back to normal, and I know you must as well. Please read the following blog from Melanie Wellington, infectious disease specialist, and keep pushing on, together! 

Theresa Brennan, MD 

I know we’d all like to be able to gaze into a crystal ball and see for sure what the future holds, especially in these uncertain times. However, as part of the Program of Hospital Epidemiology, I can tell you that we study the trends of the pandemic each and every day so that we can adjust our guidelines accordingly, with safety always the number one priority. As much as we don’t like changing things, the situation with the pandemic is constantly evolving, which means we must, too. 

I know that this isn’t easy for those of us who have worked so hard this past year to get to a point where normal felt within reach. But there is still so much we can be doing now to make a difference.  

I encourage you to get vaccinated if you haven’t done so already. It’s free through our University Employee Health Clinic and easy to schedule. Just call 319-356-3631, option 3. 

Talk to your patients about getting the COVID-19 vaccine. Remember to put empathy and compassion first. 

Finally, please remember to be a role model. Practice good safety behaviors like wearing a mask, washing your hands, and avoiding crowds. 

Let’s step up and move forward with what we know works in the fight against COVID-19. 

Melanie Wellington, MD 
Infectious Disease Specialist 

Our Stories: The importance of effective provider communication in patient care

Communication is at the center of what we do every day as humans. What I have learned is there are tools and behaviors that we can use to help us be better communicators. During the pandemic, I have learned that with improved communication comes empowerment through knowledge and sometimes, peace and comfort.

Effective communication allows us to develop common expectations, means we must not only speak clearly but also listen intently, and requires some mechanism to assure that there is a closed loop–what we think was said, is confirmed.

There is no more important communication than when we are taking care of our patients. We need to know about them and they need to understand what we are diagnosing and how we will evaluate and treat them. Unless we are on the same page, quality, safety, and the provider-patient relationship will suffer.

In this month’s blog, you will hear (and see) more about our Provider Communication Program. If you are a provider and have not attended this program, we—including your colleagues who have attended—recommend that you sign up.

Thanks for all you do!

Theresa Brennan, MD 

Communication between health care providers and patients is critical to our goal of delivering consistent, high-quality care to every individual

In our personal and professional lives, we have all experienced situations where communication might have been better. Sometimes this resulted in a simple misunderstanding, with no adverse impactOther times the result may have been a significant inconvenience, financial burden, or other unwelcome consequence.

Health care is unique, however, because poor communication can also result in poor-quality of care or poor health outcomes that could be avoided.

The good news is that everyone can improve their communication skills.

UI Hospital & Clinics’ Provider Communication Program is effective at improving provider confidence and skills as they relate to successful communication and building rapport with patients

Don’t just take my word for it though. Learn how one UI Hospital & Clinics’ provider, Kathy Lee-Son, MD, benefitted from the program.

The Provider Communication Program is free and available to all physicians and advanced practice providers (APPs) at UI Hospitals & Clinics. Successful completion of the program includes up to 4.5 AMA PRA Category 1 credits. 

To maximize the effectiveness of the program and ensure relevance of the content, each workshop is facilitated by practicing UI Health Care physicians and APPs. To help sustain, and reinforce, these critical skills, each attendee is paired with a professional coach rho will meet with them 30 and 60days postworkshop.

The Provider Communication Program workshop is also being offered 100% online through May 2021. After this date a determination to continue virtually or resume in-person sessions will be made (6 workshops are offered each month). Learn more and register for the Provider Communication Program.

Starting with this April Quest issue, the Office of the Patient Experience is excited to highlight a new Provider Communication “Booster Video” each month over the next 12 months, beginning with Skill Set #1: Beginning the Visit in the Adult Inpatient Setting.

If you have not already completed the Provider Communication Program, we sincerely hope you will join us for this rewarding and exciting experience.  

We hope to see you soon.

Alexander Nance, MHA
Director, Office of The Patient Experience

Our Stories: National Patient Safety Awareness Week

Ensuring patient safety is an essential part of providing high-quality health care and is a top priority for UI Health Care. Across the nation, health care systems will celebrate National Patient Safety Awareness Week, an annual health observance, from March 15 to March 19. National Patient Safety Awareness Week serves to increase awareness about patient safety and recognize the fantastic work by all of you and our great organization.

As we approach Patient Safety Awareness Week, please take the opportunity to reflect on the many ways in which we contribute to safe, high-quality patient care. The Quality Improvement Program has planned virtual events throughout the week to acknowledge and celebrate efforts to improve patient safety. I encourage all of you to participate.

I would also ask that you take some time to reflect on the unprecedented challenges that all health care systems have experienced this past year. Pausing to reflect will help you appreciate and be humbled by the power of team, by the power of the collective voice, and by the power of leadership that resides in each and every one of us to rise up and respond to such challenges.

It is by working together that we have and will continue to change health care. Please stay tuned to The Loop for details on UI Health Care National Patient Safety Awareness Week celebrations.

Thank you for all that you do each and every day!

– Theresa Brennan, MD


Our Stories: Staff Safety

Sometimes when we’re working, someone says something in a way that makes us uncomfortable. Often, we give people the benefit of the doubt, but if we feel threatened, we should not take chances when it comes to our safety. Everyone has the right to come to work and feel 100% safe.

It is our responsibility as leaders to provide you with a safe working environment and methods to address concerns when they arise. For the last 10 months, we have focused on how to stay safe from the virus that causes COVID -19. That is very important, and I hope you are following recommendations both inside and outside our UI Health Care facilities.

I want to highlight some of the available resources if you find yourself in a situation where you feel emotionally or physically threatened. Whether the situation involves a colleague, patient, or visitor, please know we have systems in place to address your concerns.

Following are four situations and instructions for dealing with each.

Unprofessional interaction with a coworker:

  • If you experience an unprofessional interaction with a coworker, please attempt to have a professional and productive conversation with that coworker. Wait until emotions are even and meet in a neutral and private location. Addressing conflict is a very productive way to build teams. If your conversation is not productive, if there is a power differential, or if there is a significant reason you two cannot meet, I encourage you to enter a report into the CORS (Co-worker Observation Reporting System). CORS uses a process aimed at delivering feedback in a non-judgmental way. This allows the identified staff member to reflect on their practice and associated interactions with co-workers, as well as the opportunity to self-regulate behaviors. I’ve learned we may not be aware of how we’re perceived or the impact of our words, their delivery, or our actions. Without feedback, none of us can learn. CORS provides a mirror into how we are perceived by others, insight on how that affects our team, and a gauge of the quality and safety of our care. After a CORS report is filed, trained peer messengers will share information with their colleagues to inform them about specific issues and provide the opportunity to improve their communication practices. This is an anonymous process, and information regarding who reported the incident is not shared with the peer messenger or colleague.

Threatening interaction:

  • If a workplace experience with an individual leaves you feeling threatened (i.e., he or she is exhibiting the potential for future violence or harm), but the individual is not presently violent, call Safety and Security at 319-356-2658. Safety and Security will work with the Threat Assessment Program to investigate the nature of the threat and respond accordingly. The Assessment and Care team provides an integrated and coordinated process for identifying and responding to students, faculty, staff, patients, and others affiliated with the University of Iowa who may be at risk of harming themselves or others.
  • If the person threatening you is a patient or visitor, it’s best to use language to diffuse the situation. We all have empathy and compassion for those who are sick and those who are worried about their loved ones. We may feel they are just “blowing off steam” and that we shouldn’t escalate the situation by taking their words seriously. For example, if a patient or visitor says something like “you’ll regret this,” “if he gets worse, I will be back and you won’t like it,” or “it won’t be good for you if she doesn’t get better,” their words may have been said in the heat of the moment; however, these declarations are actually signals that the person may not be thinking or acting in a logical way. These threats may also be warnings they may follow through with action and harm you or others. For example, I treated a sick patient in the ICU, and her husband was afraid he would lose her and threatened, “If she dies, I will be back with my gun.” We took that seriously and called for help. The Threat Assessment Program was great, both with our team and with the patient and her husband. He did own a weapon and may have never used it, but the Threat Assessment Program protected us. As in many of these situations, the husband regretted his words. By directly addressing this threatening interaction, we discussed boundaries and better methods for expressing his concerns in the future.

Violent interactions with a patient:

  • A Code Green violent patient management team is available to respond to potentially violent patient situations. Any staff member may declare a Code Green by dialing 192 if assaultive, combative, or uncontrolled patients pose a threat to themselves, staff members, patients, visitors, or hospital property. When calling the Code Green number, please:
    1. Identify that you need the Code Green team
    2. Identify yourself
    3. Identify the unit, building, and room number where help is needed.

Violent interactions with a visitor, family member, or staff member:

  • Contact Safety and Security by dialing 195 or 911 during situations when visitors, family, or staff are being disruptive, hostile, or threatening others. Safety and Security will work with hospital administration and local law enforcement agencies to control these situations.

As I mentioned above, we have resources available for all our staff members. If you’ve experienced a threat or violence, please seek emotional support after this event from any of the following sources:

  • The COPE team is comprised of volunteers including chaplains, physicians, social workers, psychiatrists, nurses, therapists, and others and strives to provide emotional support and healing to health care providers who have experienced difficult situations.
  • The Employee Assistance Program (EAP) provides integrated services to faculty, staff, and their family members to promote emotional well-being and to increase engagement and productivity among members of our UI community.
  • Office of the Ombudsperson is a resource for any member of the university community— including students, faculty, and staff—with a problem or concern. They provide informal conflict resolution, mediation services, and advocacy for fair treatment and fair process.
  • Diversity, Equity, and Inclusion @Iowa provides services related to human rights, anti-harassment, violence, anti-retaliation, and discrimination.
  • The Office of Diversity, Equity, and Inclusion provides cultural enrichment and acclimation programs for members of the Carver College of Medicine and UI Health Care community.
  • Office of the Sexual Misconduct Response Coordinator (OSMRC) coordinates the university’s response to reports of sexual harassment and sexual misconduct.
  • Ethics Point should be used to file an anonymous complaint related to a financial crime or misconduct.

Just as you hear at the Eastern Iowa airport: “If you see something, say something,” you should apply this idea at work as well. Know your resources and have a plan to utilize them if the need arises. Your safety matters, as does the safety of your team.

UI Health Care is on a constant quest for improvement, and as an institution we can’t address what we don’t know. We want to hear from you.

I wish you a happy and safe 2021. I am hoping for a year where we all have many opportunities to share our great stories. Thanks for your perseverance, your resiliency, and all you do each and every day.

– Theresa Brennan, MD

UIHC Policies Manual 
Code Green Violent Patient Management Policy EOC-Safety-01.030 
Workplace Violence Policy, EOC-Security-02.007

Our Stories: Covid-19

Unfortunately, COVID-19 is now another one of “Our Stories.” It is in our community and I would venture that each of you has now have someone you know who has been infected. When this occurs, and when we see community transmission of infections locally, it becomes very personal. This leads each of us to begin to think about and worry about many things. For you, the issues are magnified as you are health care workers.

This blog has been devoted to “Our Stories” from the beginning and for most of them they are very positive. COVID-19 is not a positive story, but I think there are things we can do make it into one.

I would offer three things:

  1. First, all those working within UI Health Care are not new to facing great and complex challenges. It was recently said that we are made for this and I agree.  No matter what happens, we will FIGHT this and we will ultimately win the battle.  We can only do this, though, by standing together.
  2. Second, our community has been amazing in joining us in this battle. Be grateful for the entire UI Health Care team and our community. Show your gratitude with the WE STAND TOGETHER campaign.
  3. Finally, focus on what we can control, and focus on the positive. I am disappointed by all the negative that we see today. Be empowered, and focus on the positive.

Together, we’ll get through this.

Our Stories: Patient Safety is a Team Sport

March 8 to 14 has been designated as Patient Safety Awareness Week. The Institute of Medicine’s report, To Err is Human, has been transformational for patient safety. The report brought to light that many errors in health care result from a culture and system that is fragmented and that improving health care requires a team approach. Several major points in the report are that errors are common and costly, systems-related problems cause errors, errors can be prevented, and safety can be improved. Twenty years later, the Patient Safety movement has produced learnings that demonstrate significant improvement in the care patients receive, and conversely that many opportunities remain.

Health care organizations are in a constant state of stress due to high patient volumes, complex, sicker patients and staff shortages. UI Hospitals & Clinics is not protected from these challenges. Daily we prioritize and re-prioritize throughput issues, discuss barriers to discharge, navigate the impact of behavioral health on patient and staff safety, accommodate medication shortages, and at this point in time, strategically plan how we will respond to an impending pandemic related to coronavirus.

Who we are as an organization and how we responsibly engage in the work of patient safety could not be more important. In the past five years much work has been accomplished to implement and operationalize a quality and safety structure that has reduced fragmentation and emphasized alignment of quality and safety work across the organization. This alignment creates greater critical mass and collective voice around quality and safety priorities, and in turn establishes health care as team sport, allowing us to continue to improve the care we provide patients.

In addition, senior leadership continues to invest in tools and programs that will influence UI Hospitals & Clinics’ ability to achieve and sustain excellence in care delivery free of preventable harm. On March 9, we will launch a new incident reporting system, Riskonnect. The new system is intuitive with a user-friendly platform, provides improved detail in event reporting and analytics, and system availability of Root Cause Analysis (RCA), peer review, and claims modules providing one protected location for all event review information. This past week, training was provided on how to communicate and disclose information to patients and families that have experienced a harm event. In the near future, we will make a decision on a Just Culture consultant who will partner with us over the next couple of years to establish systems of strong accountability for safe practices in which healthcare is delivered.

As we approach Patient Safety Awareness Week, take the opportunity to reflect on the many ways in which we contribute to the provision of safe, high quality patient care. I invite you to participate in the activities that have been planned here at UI Hopsitals & Clinics. And last but not least, I encourage you to take the opportunity to thank the members of your team, those you work closely with each and every day, to ensure we make a difference in the lives of those we care for!

Beth A. Hanna, BSN, RN, MA
Director, Quality Improvement Program

Our Stories: Practicing gratitude

Our national history shows that in 1621, the Colonists and their Native American allies, the Wampanoag, shared a harvest feast.  This is thought to be one of the first thanksgiving celebrations in the United States.  This tradition continued, on and off, until 1863 when Abraham Lincoln proclaimed the fourth Thursday of November to be a national holiday—Thanksgiving.

These original “feasts” were really a celebration of life based on a successful harvest during times of significant hardship.  They celebrated their crops and they celebrated their families and friends.  This holiday is referred to by some as a day to celebrate with happy gratitude.  Many of us are blessed to be able to have this time of celebration with our family and friends.  Although we celebrate today, for many of us as a day of excess, the original Americans celebrated their ability to survive.

As your chief medical officer, a physician, and a patient, there is much for me to reflect on with happy gratitude.  We have a fantastic team who takes excellent care of our patients each and every day, and does it through unconditional support of each other.  Though there are times when we stumble, as the need arises the team with UI Health Care can always be counted on to rise to the occasion and bring forth our best.  I would be living in fantasyland if I did not also recognize the many hardships that we face each and every day.  Though our struggles are different than those first Americans, the effort required to overcome them are just as great.

I write to you today to express my sincerest gratitude for what you do each and every day for our patients, their families, and all who work at UI Health Care.  Although we all, I may be the worst, tend to look toward tomorrow and how we can be better, now is an excellent time for us to look back and celebrate.  I recently received an unsolicited note from a patient:

“… whomever is responsible for the amazing turnaround that appears to have occurred in patient services at UIHC should be commended and recognized. I have a considerable history at UIHC …. and have experienced the best care I could imagine. However, the services surrounding the direct care, as you know, have not always been great.

“Things have obviously changed for me and, I assume, others. For example, I walked into the digestive disorders clinic one afternoon bleeding from a polyp removal.  The staff said Dr, Gerke would be a minute. Dr. Gerke, completing a procedure  on another patient, met with me and indicated that though it didn’t appear to be an emergency he couldn’t be sure.  I could either go to the emergency room, stay the night and get prepped for a colonoscopy the next morning or, surprisingly, go back with his team and have the procedure, unsedated, NOW.   I chose the ‘NOW.’ I left an hour later, repaired, impressed, and laughing about the experience and pain.  There is no place in the world I could have gotten that kind of care.

“Though not as dramatic my recent experiences with your other clinics have also improved my perceptions of UHIC patient care and services. I hope your success continues. “

“Whomever is responsible”, is you!  And this is only the start.  Did you know that in fiscal year 19, we:

*The following numbers are rough estimates
  • Provided around 2,593,606 million meals
  • Volunteered over 110,000 hours
  • Cared for over 55,000 ETC patients (with over 740 being transported via AirCare)
  • Preformed over 34,000 surgical procedures
  • Provided over 315,000 radiographic exams and treatments
  • Filled over 2.2 million pharmacy orders
  • Provided around 5.5 million laboratory tests
  • Trained over 1800 students in Health Education
  • Provided over 220,000 social service consultations
  • Privileged 258 new providers, modified 120 current providers, and reaffirmed 762 providers
  • Submitted 15,811 PSNs
  • Submitted 218 NIH grants
  • Published 2,797 research pieces

And since January 1, 2019, we have:

  • Cared for over 27,755 inpatients
  • Delivered over 2,111 babies
  • Saw and cared for around 890,000 patients in clinics
  • Helped over 325 colleagues COPE with a challenging work-related experience

And we have successfully undergone 4 accreditation visits from the Joint Commission including our massive triennial survey.

All of this while improving our surgical site infection rates, our central line blood stream rates, our medication errors, our hospital acquired pressure ulcers, and our patient satisfaction metrics in nearly every category and achieving an all time high on our nurse and doctor communication HCAHPS.   And there is some much more to this amazing story….

This is Our Story and it makes me proud and filled with happy gratitude.   Take a moment to step back and be grateful to yourself and to quote one of our quality leaders, “Go (continue to) Be Great”!!


—Theresa Brennan, MD, Chief Medical Officer

Our Stories: Making Difference through Documentation

Accurate clinical documentation is essential to patient care. The medical record allows us to have asynchronous communication among the many team members and with our referring physicians. Telling the patient’s story, accurately, in the medical record allows for the highest quality and safest care for our patients. Documentation also lends to appropriate risk assessment of our patients. This is a critical way to assess our quality of care. Finally, clinical documentation leads to medical coding which results in overall payment for inpatient admissions. For all of these reasons, it is our duty as health care professionals to make sure that our documentation is accurate and complete. I have asked Deanna Brennan, director of Clinical Documentation Improvement to lead this month’s blog and discuss accurate and complete documentation. 

As we move into the month of May, I am excited to have the opportunity to share our program with you and answer your questions regarding how clinical documentation impacts our organization and why it’s such an important piece of your daily work. As the director of our Clinical Documentation Improvement department for the past three years, I have had the opportunity to hear the daily frustrations that many of you have regarding documentation requirements, queries, and coding nuances. One of the most common questions I hear from providers is, “What difference does it make?” To answer that question, your documentation has the potential to make a tremendous difference in accurately reporting the complexity and acuity of the patients you care for. In turn, this data is used to show the excellent care that we give, and that University of Iowa Hospitals & Clinics is a high-quality organization that cares for highly complex patients with excellent patient outcomes. 

Clinical Documentation Improvement programs are an integral part of health care facilities across the nation, facilitating high level accuracy of documentation and coding. These programs are made up of clinical documentation specialists that partner with providers and coding teams to impact documentation quality, patient outcomes, and accuracy of data analytics. UI Hospitals & Clinics implemented the Clinical Documentation program in 2004, with the assistance of eight “DRG nurses” who reviewed charts and assigned a documentation related grouper (DRG) that reflected the patients’ care needs, acuity of illness and expected length of stay.  As focus on documentation and coding increases, the UI Hospitals & Clinics program has evolved to take on new projects, challenges, and improved engagement strategies to help our organization achieve its mission. 

Through its daily efforts, the Clinical Documentation Improvement (CDI) team works with providers to ensure medical records contain a complete and accurate picture of the patient’s level of care, severity of illness, and risk of mortality, while also supporting necessary resource utilization. The CDI nurses help to ensure that the record supports accurate capture of documentation codes, statistical data, quality metrics, and reimbursement. This is accomplished through ongoing education and collaboration among the CDI nurses and various specialty teams.

The department works as a liaison service for multiple areas of the hospital, using data analytics to identify areas of opportunity for improved documentation. CDI uses a teamwork mentality to partner with services, provide education, and identify areas of focus to improve documentation accuracy. The department provides regular feedback to providers regarding individual patient records, takes part in chart review discussions, and provides resources for documentation improvement.

Our department is comprised of 16 clinical documentation specialty nurses and a quality oversight specialist. The team’s primary purpose is concurrent review of medical records to improve accuracy, clarity, and specificity of provider documentation. They bridge the gap between providers and hospital coders by clarifying at-risk documentation prior to claim submission. They collaborate extensively with physicians, coding staff, and other patient caregivers to improve accuracy and completeness of acute inpatient documentation. They must adhere to ethical and professional business practices as governed by the Association of Clinical Documentation Improvement Specialists (ACDIS) and the American Health Information Management Association (AHIMA).

Clinical Documentation Improvement is a specialized field that utilizes highly experienced nurses with a diverse clinical background, requiring them to acquire proficient coding skills and knowledge. CDI nurses must have the ability and willingness to seek out changes in healthcare reform and coding regulations, then incorporate those changes into their practice. These nurses must possess a high level of organization and computer skills, comprehensive medical knowledge, and utilize effective communication. These capabilities help them to identify gaps in the clinical documentation.

The CDI department at UI Hospitals & Clinics is an excellent resource for providers wishing to increase their knowledge of documentation requirements and improve accuracy and completeness of medical records. In the past year, CDI has partnered with a variety of specialty services, such as the Heart and Vascular Center and neurosurgery, to help identify opportunities for documentation improvement for accuracy and completeness. CDI continues to look for opportunities to educate, collaborate, and improve clinical documentation throughout our organization. If you or your team wish for increased engagement from the CDI program or if you wish to learn more about documentation improvement and engage in educational opportunities, please contact our program with information below.

Thank you for the excellent care you give to our patients and for your attention to the impact that your medical record documentation has on our organization.

Deanna Brennan, RN, BSN, CCDS
Clinical Documentation Improvement manager/director

Clinical Documentation Improvement
Pager #5496 or

Manager/director: Deanna Brennan, deanna-brennan@uiowa.edu
Quality oversight specialist: Jaime Sherman, Jaime-sherman@uiowa.edu