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

Contact:
Clinical Documentation Improvement
Pager #5496 or CDI-RN@uiowa.edu
Manager/director: Deanna Brennan, deanna-brennan@uiowa.edu
Quality oversight specialist: Jaime Sherman, Jaime-sherman@uiowa.edu

I am pleased to have Beth Hanna, director of our Quality Improvement Program, as our guest author for the CMO blog this month. As we all are aware, quality revolves around our patients. High quality care with elimination of preventable harm is what we must strive for every day, and we do! Please take some time to read Beth’s very well done blog, and as usual, please contact us with comments.  

National Patient Safety Week was celebrated March 10–16, 2019. University of Iowa Health Care will celebrate Patient Safety Week April 29 to May 3 in partnership with the Quality Improvement Program, Department of Nursing, and the Office of the Patient Experience. Twenty years have passed since the Institute of Medicine, renamed the National Academy of Medicine in 2015, published To Err is Human: Building a Safer Health System. The report garnered the attention of many because it estimated that as many as 98,000 hospitalized patients in the United States die each year as a result of patient safety failures. Subsequent articles have suggested the number may be much higher. Regardless, this report heightened the nation’s awareness of the risk to those hospitalized and the urgency to further understand and mitigate risk moving forward.

Make no mistake, achieving patient safety is a journey—a journey constantly challenged by the complex, dynamic environment in which patient care is delivered. It’s a continuous search for ways to improve the quality and safety of care in a time of overcrowded emergency departments, hospital census at capacity, and ever-more complex and sicker patients. In an effort to leverage quality, safety, and performance improvement practices to mitigate risk in one area, risk may be created in another.

So how do hospitals persevere in such challenging times? As part of UI Health Care’s effort to eliminate harm to patients in every setting, the leadership of our organization has invested in and supported a number of strategic initiatives over the past few years to influence our ability to achieve safety for all. In 2016 a quality and safety structure was implemented consisting of five domains: Surgical Procedural, Adult Inpatient, Children and Women’s, Ambulatory, and Shared Services. Associate chief quality officers and nursing leaders are responsible for the organization of quality and safety committee structures within each domain. In March 2016, the Quality and Safety Oversight Subcommittee held its inaugural meeting. The subcommittee is comprised of 44 members who meet the first Monday of every month. At this same time, a new provider role, physician value officer, was incorporated into the hospital quality and safety structure.  And most recently, in January 2019, Clinical Quality, Safety, and Performance Improvement (CQSPI), Operations Excellence (OE), and Nursing Quality staff have formally integrated into one program, the Quality Improvement Program. Lastly, effective March 18, 2019, we re-launched the Quality Improvement Database, creating a central repository of institutional performance improvement initiatives.

As we establish and operationalize a more integrated and aligned quality and safety structure, we are positioned to more efficiently and effectively mobilize each and every one of us to address the risks that we face—to be the system that provides high quality, patient-centered care free of all preventable harm. Our greatest resource is all of you, who get up each and every day to provide the best possible care to patients who entrust their lives to us. The dedication, commitment, and work ethic of our staff, our team, is second to none.

As we approach the next fiscal year, the goals of the organization are being set. The goals are ambitious and necessary to continue advancing the cause of quality and safety. We look forward to partnering with all of you as we continue on our journey. As mentioned at the beginning of this blog, UI Health Care will celebrate Patient Safety Week April 29 to May 3. Take time to participate in the activities!

Thanks for making a difference!