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1 To Err Is Human: CDI Impact on Patient Safety Indicators Kathleen Shindle, RN, BSN, CCDS, CDIP Allison Clerval, RN, BSN, CCDS, CDIP Clinical Supervisors Thomas Jefferson University Hospital Philadelphia, PA 1 Learning Objectives At the completion of this educational activity, the learner will be able to: Identify strategies for CDI staff to recognize potential PSIs during concurrent review Recognize the inclusion and exclusion diagnoses and procedures Define CDI and coding role in impacting PSI Implement lessons learned from case study review 2 Our Background Thomas Jefferson University Hospital Center City Campus Jefferson Hospital for Neuroscience (JHN) Methodist Hospital Abington Hospital/Aria Health Clinical documentation staff at TJUH, Inc. Senior director of HIM and clinical documentation Director of clinical documentation 3 clinical documentation supervisors 23 clinical documentation specialists 3

2 Defining Patient Safety Indicators Medical errors Types of errors Causes U.S. healthcare system Patient care Expense Patient safety History Patient Safety Indicators we do/advocate civil justice system/issue advocacy/medical errors 4 Defining Patient Safety Indicators 25 Patient Safety Indicators Hospital Acquired Condition Reduction Program (HACRP) Hospital Value Based Purchasing Program (VBP) Inpatient Quality Reporting Program (IQR) PSI 90 for CMS PSI 90 for AHRQ 5 Steps for Attendees to Answer/View POLLING QUESTIONS 1. Navigate to the event Agenda in the main menu 2. Tap the name of the current session to view the session details page 3. Tap Polls 4. Tap the name of the poll 5. Tap your answer choice and then tap Submit 6

3 Polling Question 1 Does your CDI program query concurrently for patient safety indicators? Yes No Don t know 7 PSI 90 Timeline at TJUH Initiation Second level coding review Targeted physician education Researched use of AHRQ software Continued growth Transitioned to Surgical Missed Opportunities Group Creation of Clinical Quality Metrics Group Clinical documentation quality coordinator Evolution Continued physician education Staff education Evolution of review process Physician peer review with all PSIs 8 Monitoring Patient Safety Indicators Building an interdisciplinary team Clinical documentation Supervisors Director Coding Clinical documentation quality coordinator Advisory coder/director Performance improvement Nurses Data analysts Chief patient safety & quality officer Physicians Respiratory therapy CMO/CNO 9

4 Defining PSI 90 PSI 03 Pressure Ulcer Rate PSI 06 Iatrogenic Pneumothorax Rate PSI 07 Central Venous Catheter Related Bloodstream Infection Rate PSI 08 Postoperative Hip Fracture Rate PSI 12 Postoperative Pulmonary Embolism or Deep Vein Thrombosis Rate PSI 13 Postoperative Sepsis Rate PSI 14 Postoperative Wound Dehiscence Rate PSI 15 Accidental Puncture or Laceration 10 Risk Adjusting for PSI PSI 90 Case Examples 12

5 Polling Question 2 Is your CDI staff educated on querying for PSI exclusion criteria? Yes No Don t know 13 PSI 3: Pressure Ulcers Inclusion opportunities Definition Exclusion that supports coding 14 PSI 3: Pressure Ulcers 15

6 PSI 3: Pressure Ulcers Query Query Response 16 PSI 6: Iatrogenic Pneumothorax Inclusion opportunities Definition Exclusion that supports coding 17 PSI 6: Iatrogenic Pneumothorax Technical Specifications 18

7 PSI 6: Iatrogenic Pneumothorax Technical Specifications 19 PSI 6: Iatrogenic Pneumothorax Technical Specifications 20 PSI 6: Iatrogenic Pneumothorax 21

8 PSI 6: Iatrogenic Pneumothorax Query Query Response 22 PSI 7: Central Venous Catheter Associated Bloodstream Infection Inclusion opportunities Definition Exclusion that supports coding 23 PSI 7: Central Venous Catheter Associated Bloodstream Infection XX 24

9 PSI 7: Central Venous Catheter Associated Bloodstream Infection Laboratory Findings Treatment 25 PSI 7: Central Venous Catheter Associated Bloodstream Infection Query Response 26 PSI 8: Postoperative Hip Fractures Inclusion opportunities Definition Exclusion that supports coding 27

10 PSI 9: Perioperative Hemorrhage & Hematoma Inclusion opportunities Definition Exclusion that supports coding 28 PSI 9: Perioperative Hemorrhage & Hematoma Acute blood loss anemia vs. Hemorrhage complicating a procedure 29 PSI 9: Perioperative Hemorrhage & Hematoma Operative Report At the completion of the case, the neck was copiously irrigated. Valsalva was undertaken to make sure there was no bleeding and the nerve stimulated with 0.8 ma of energy. A parathyroid superiorly was identified in the neck and preserved. Once the neck was deemed to be hemostatic, I then placed a 10 French JP drain and closed the neck with 3 0 Vicryl, 4 0 Monocryl and Steri Strips. 30

11 PSI 9: Perioperative Hemorrhage & Hematoma Query Query Response 31 PSI 11: Postoperative Respiratory Failure Inclusion opportunities Definition Exclusion that supports coding 32 PSI 11: Postoperative Respiratory Failure 33

12 PSI 11: Postoperative Respiratory Failure 34 PSI 11: Postoperative Respiratory Failure 35 PSI 12: Perioperative Pulmonary Embolism or Deep Vein Thrombosis Inclusion opportunities Definition Exclusion that supports coding 36

13 PSI 12: Perioperative Pulmonary Embolism or Deep Vein Thrombosis 37 PSI 12: Perioperative Pulmonary Embolism or Deep Vein Thrombosis Query 38 PSI 13: Postoperative Sepsis Inclusion opportunities Definition Exclusion that supports coding 39

14 PSI 13: Postoperative Sepsis 40 PSI 13: Postoperative Sepsis Query XXXX 41 PSI 13: Postoperative Sepsis Query Query Response 42

15 PSI 14: Postoperative Wound Dehiscence Inclusion opportunities Definition Exclusion that supports coding 43 PSI 14: Postoperative Wound Dehiscence 44 PSI 15: Accidental Puncture or Laceration Inclusion opportunities Definition Exclusion that supports coding 45

16 PSI 15: Accidental Puncture or Laceration 46 PSI 15: Accidental Puncture or Laceration Query 47 PSI 15: Accidental Puncture or Laceration Query Response 48

17 PSI 15: Accidental Puncture or Laceration Terms that indicate an accidental puncture or laceration Inadvertent, inadvertently Complication Complicated by Accidental, accidentally Unintended Unintentionally Unexpected, Unexpectedly Surgical tips: Punctures & lacerations Terms that suggest a non accidental puncture or laceration To facilitate Necessary Required Intentional Intended Inherent Integral Routinely expected 49 PSI 90 Education 50 PSI Education Staff Tip cards Physicians Education Guidelines Attribution policy Coding 51

18 PSI Education Inclusions and exclusions Immunocompromised diagnoses Pancytopenia/neutropenia Chronic kidney disease (unspecified or stage V)/ESRD Severe malnutrition/nutritional marasmus Immunocompromised procedures Organ transplants Bone marrow transplants Coagulation disorders 52 Using Data to Gain Physician Buy In Clinical quality metrics meeting Surgical missed opportunities meeting Physician champions Surgery Vascular medicine CMO Medicine hospitalist UHC Ranking U.S. News & World Report 53 Evolution of CDI and Coding Roles PSI reviews Operative reports Querying Inclusions/exclusions Collaboration Concurrent versus retrospective CDI supervisors & quality coordinator Monitoring Spreadsheet Query reports 54

19 PSI 90 Workflow Decision Tree 55 CDI Role in Hospital Based Committees Clinical quality metrics Core Measures PSI 90 Surgical missed opportunities PSI 4 Death Among Surgical Patients PSI 6 Iatrogenic Pneumothorax PSI 9 Perioperative Hemorrhage/Hematoma PSI 11 Postoperative Respiratory Failure PSI 13 Postoperative Sepsis PSI 15 Accidental Puncture/Laceration Hospital DVT group PSI cases Line associated DVTs Hospital acquired DVTs Clinical interventions 56 PSI 90 Progress in Action 57

20 Upcoming Changes for PSI 90 for AHRQ Name change Removal PSI 07 Number of component indicators increased PSI 09 PSI 10 PSI 11 Changes made to PSI 08, PSI 12, and PSI 15 PSI Weight Shift Adoption by CMS 58 Reflecting the True Clinical Picture True quality of patient care Create solutions Physician education Clinical Find better alternatives Devices Complications Meet the challenges ahead 59 Thank you. Questions? In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide. 60