Critical Path Network

Specialists track core measures, documentation, DRGs

RNs work on team with case managers, social workers

Kettering Medical Center has found a solution to the challenges case managers face when they have to manage the daily care of patients, plan for discharge, work with insurance companies, and ensure that the hospital is meeting its targets for quality initiatives.

The case managers, who are part of the hospital's quality department, work as a team with the hospital's clinical documentation specialists, highly experienced bachelors- and masters-prepared nurses who review the charts every day for documentation issues and quality measures.

"Case managers can't do everything. If case managers are responsible for core measures, documentation, and making sure the DRGs are correct on top of their other duties, some things are likely to get dropped by the wayside. I don't see how case managers can do justice to quality initiatives along with their other responsibilities," says Liz Wise, RN, BSN, administrative director for clinical quality at the Dayton, OH, medical center.

At Kettering, case managers are unit-based and work as a team with the social workers, coordinating the care for between 20 and 30 patients. The clinical documentation specialists also are unit-based and work as part of the team.

Case managers focus on the plan of care and are responsible for utilization review, working with the insurance company and reviewing quality issues for the hospital's peer review committee.

"The case managers look at the whole aspect of patient care, including avoidable days and denials, and work closely with the insurance companies and physicians," Wise says.

Using the hospital's electronic case management system, the case managers review the charts daily and refer any quality issues to the hospital's peer review committee.

The clinical documentation specialists work closely with the case managers and social workers and review the charts every day for quality issues and documentation.

"When we created the clinical documentation specialist position in 2001, their responsibility was to review the charts for documentation and making sure that patients were placed in the right DRG. They work closely with physicians and make sure that everything that is done for the patient is documented," Wise says.

Now, the clinical documentation specialists are a vital part of Kettering Medical Center's pay-for-performance initiatives.

Kettering Medical Center, which includes Kettering Memorial Hospital and Kettering-Sycamore Hospital, was one of the top-scoring medical centers during the first year of the Premier-CMS pay-for-performance demonstration project. The hospital received a total of $92,095 in the first year of the demonstration project. Preliminary estimates show that the hospital will receive a significantly larger amount for the second year of the program, according to Kettering Medical Center's clinical quality decision support department.

In addition, the hospital participates in the Surgical Infection Prevention (SIP) and Surgical Care Improvement Programs (SCIP) through CMS and Premier.

"The clinical documentation specialists were looking at charts anyway and talking with physicians. We added the pay-for-performance project to them," Wise says.

During their chart review, the unit-based clinical documentation specialists make sure that the core measures are being followed and that medication reconciliation sheets are completed correctly.

"They work together as a team with the case managers and work closely with the nurse managers and the charge nurses. They follow the patients closely, working with the physicians to make sure they have everything documented in the chart," she says.

Clinical documentation specialists

The clinical documentation specialists are RNs with at least a bachelor's degree and at least five years experience in a specific disease area and who have served in a leadership role for two or more years. Other requirements include excellent computer skills, an understanding of databases, and the ability to conduct educational sessions and PowerPoint lectures.

"This is the only way that someone would know the right questions to ask the physicians. We wanted them to be very knowledgeable clinically so they'll be looked at as a credible resource," Wise says.

For instance, she points out that the medical records staff can code only using what a physician writes on a chart, not what is on the laboratory reports or outcomes from other procedures. That's why it's essential that the people doing documentation review have extensive knowledge of that diagnosis and be able to interpret the reports, Wise says.

"If someone doesn't know and understand the diagnosis, they can't read between the lines and ask the physician to clarify his documentation to reflect the true condition of the patient," she says.

The clinical documentation specialists' standard caseload is 20 to 30, the same as case management.

"They are responsible for knowing every patient on their unit. They review all new charts each day and never go longer than three days without reviewing the chart," Wise says.

They review the charts of patients whose diagnosis falls under the core measures every day. If the DRG does not have a core measure, they review the chart every three days.

On a daily basis, the clinical documentation specialists typically review six to 10 new admissions.

The clinical documentation specialists communicate frequently with the case managers and the social workers and work closely with them to make sure that all the quality measures are being documented.

For instance, if a case manager is reviewing the chart of a patient with congestive heart failure and sees that some of the core measures have not been followed, she'll mention it to the clinical documentation specialist, who will make sure the measures are followed.

The nurses, case managers, and clinical documentation specialists have an informal meeting every morning, and sometimes more frequently, to make sure that everyone on the team is aware of who is new on the unit and what issues are outstanding. Each unit has an interdisciplinary team meeting at least once a week.

In June 2005, the hospital started a concurrent documentation analysis process to supplement the retrospective quality measures analysis turned in for national ratings.

"When hospitals turn in their data for national performance improvement projects, it may be six to nine months before they get the score. By that time, in most cases, changes in Medicare have already taken place," Wise says.

The hospital uses its electronic case management software to gather the information concurrently.

"Within 30 days of a patient's discharge, the information that was collected concurrently is then validated in our working system and sent electronically to the Ohio Hospital Association, the Centers for Medicare & Medicaid Services, or the Joint Commission on Accreditation of Healthcare Organization and Premier. This way, we have to input the information only once, and that is concurrently," she says.

By collecting data on a concurrent basis, Wise can run daily, weekly, and monthly reports showing variances by unit and by physician.

"We are able to take that back to the unit and talk about it on a daily basis, during team meetings between nursing, the case manager, and the clinical documentation specialists. We are able to send the report monthly to the service line, physicians, and nursing management so every unit knows how many variances it had that month," Wise says.

At Kettering Medical Center, the charts stay on the units for 24 hours after discharge, giving the clinical documentation specialists a chance to review the discharge to make sure everything is in order.

The case managers and the discharge planners complete all data before the chart is moved. They make sure that the information is the same in the medical records sheet and the discharge summary.

"In the past, the charts were picked up the day of discharge and if all the documentation wasn't complete, the case managers couldn't always follow through until the chart was already in medical records. This saves a trip to the medical records department to make sure everything is documented," she says.

The physicians like having the charts stay on the unit longer so if they don't get the discharge summary completed the day of discharge, they know the chart will be available the next morning.

Making the chart more complete saves time in medical records because no one has to re-compile the chart, Wise says.