Proactive approach improves documentation

CMs assess patients before they are moved to a bed

A proactive approach to documentation improvement has paid off for Northwest Hospital and Medical Center in Seattle.

"Documentation and other proactive initiatives have had a positive impact on the hospital financially, but more importantly, they also have resulted in better patient care," says Becky Budke, MSN, director of care management, performance improvement, and medical staff services for the nonprofit community hospital.

The hospital is 30% ahead of the state average for risk of mortality variance. The hospital has also received the 2007 Distinguished Hospital Award for Patient Safety from HealthGrades, indicating the hospital's placement in the top 5% of the nation's hospitals for patient safety.

"Paying diligent attention to physician documentation projects has impacted our case mix index, risk-adjusted mortality, severity of illness, and patient status. We have experienced significant improvements in each of the four areas," Budke adds.

At Northwest Hospital and Medical Center, case managers partner with social workers to manage the care of patients on the unit to which they are assigned.

Together, the two disciplines are responsible for a maximum census of 18 patients. The social workers oversee the discharge planning and typical social work functions. They see about 70% of patients. The nurse case managers are responsible for 100% of the patients, handling utilization management, DRG assignment, appropriateness for admission and continued stay, and communicating with payers.

The disciplines work together when patients have complex discharge needs, such as wound care or IV antibiotics.

The hospital's documentation improvement initiative is twofold — patient status and DRG assurance — and both parts are spearheaded by case managers.

Every patient who is admitted through the emergency department is assessed for admission status, using InterQual criteria, either by a case manager or a nursing supervisor.

The case managers rotate being on call to the emergency department and have a commitment to answer their page within 15 minutes.

The admitting representative pages the case manager or supervisor when a patient has the potential for being moved to a bed. The patient is assessed using InterQual criteria before he or she can be moved.

Working in real-time

"We are determining whether a patient meets inpatient or observation status in real-time and are not reacting to it. It's far more efficient for case managers to conduct the review on the front end than to react to it after the patient has already been admitted," Budke says.

The nursing supervisors have been trained to review the patients when the case managers are not in the hospital.

"When we first tackled patient status, there was no documentation in the medical record to support patient status, and the physicians were very inconsistent with their orders," says Susan Truscott, BS, CCM, clinical documentation coordinator at the hospital.

The case management team educated the emergency department staff and physicians throughout the organization on what clinical criteria are required for patients to meet inpatient or observation status. Now every chart has a place for the physician order indicating patient status as well as a copy of the InterQual review.

For the DRG assurance program, the case managers work in partnership with the coders and physicians to ensure that documentation is in place to support the correct DRG before the patient is discharged.

When the hospital embarked on the DRG documentation improvement project, it called in an outside vendor who conducted a chart audit and identified opportunities of improvement, including DRG assignment and accurate reflection of severity of illness and risk of mortality for the hospital's patient population.

The case managers, coding staff, and physicians went through intensive training on documentation before the initiative began.

Now, the case managers work with physicians for documentation in real-time rather than the coders working with the physicians on documentation retrospectively.

Assigning the correct DRG concurrently, rather than retrospectively, has helped the hospital improve compliance with The Joint Commission and Centers for Medicare & Medicaid Services' hospital quality measures, Budke says.

When a patient is admitted into the hospital, the case manager reviews the charts and assigns a working DRG, consulting the coding staff with any questions. The coders and case managers have regular meetings and talk daily on a case-by-case-basis.

"Coders keep us up to date on changes in coding so we can adjust our queries and educate the physicians. We make sure the documentation is solid before they touch the chart so they don't have to do as much retrospectively," Truscott says.

The case management department has developed a bright-green lime sheet on which case managers write queries to physicians about documentation and record questions about potential complications and comorbidities to ensure that the physician's document is in a language that can be coded.

The sheets stick out of the charts about ¼-inch so the physicians notice them immediately. Physicians can check off, "Yes, I agree and I'll document it," or, "No, I disagree."

Speaking in codeable language

"We spell out what we see and what they are treating and ask if it's possible that the patient has a particular condition. We work with the doctors on putting their documentation into codeable language," Truscott says.

Because of their training, physicians tend to write down symptoms and lab results, rather than using words that can be coded, she adds.

For instance, the doctor may write "low hematocrit count, give transfusion" when the codeable phrase is "blood loss anemia, will transfuse."

"We educate and collaborate with the physicians, because, ultimately, it's the physician documentation that drives the severity of illness and the risk of mortality," Truscott says.

Budke watches for trends in the number of queries and query responses to determine if the queries were appropriate and whether they were answered.

"We can drill down to how many queries each doctor been asked, how many he or she answered, and how many were not answered," Budke says.

If some of the queries seem questionable or unclear, she educates the case manager responsible. If it's a physician problem, the medical director reviews the chart and calls that physician.

"If the omission affected severity of illness or risk of mortality, or the presence or absence of a complication or comorbidity, the physician may be notified regarding his or her documentation," Budke says.

Any time a physician fails to answer a case management query, the coders may send a retrospective query.

"This has resulted in fewer queries that go unanswered. It's difficult for the physicians to remember everything about a case after the patient is discharged and they have to review multiple pages from the chart in order to answer the query retrospectively. It's much easier for them to answer queries while they are managing the care of the patient," Truscott says.

Some documentation problems come up frequently, Truscott says.

Among those are: documenting "anemia" instead of "blood loss anemia;" distinguishing between controlled or uncontrolled diabetes; improper documentation of sepsis; and using incorrect documentation for community-acquired pneumonia and aspiration pneumonia.

The other area in which the case managers are constantly educating the doctors is the use of up and down arrows to document, instead of codeable language.

For instance, doctors may use a K with an arrow pointing up to designate hyperkalemia or elevated levels of potassium in the blood.

"This is a hard habit to break because they've been doing it for so long but we need words written out to be able to document it," Truscott says.

At Northwest Hospital and Medical Center, case management reports to the chief medical officer.

"This works well because many of the things we're trying to accomplish are physician-related, such as issues with documentation and patient criteria. Having support from the physician leader adds credibility and facilitates collaboration with physicians," Budke says.