COCOA: A multi-disciplinary collaboration to reduce HACs through appropriate documentation

Nancy Rae Ignatowicz, RN, MBA, CCDS

Provena Health, System Manager Clinical Documentation

[email protected]

COCOA: A multi-disciplinary collaboration to reduce HACs through appropriate documentation

Audience

• Physicians

• Infectious disease physicians

• Nurses

• Coders

• Epidemiologists

• Infection control practitioners

• Other

I am glad you came to hear the stories behind the slides!

• How many of you have had quality or infection control tell you that you coded the chart wrong?

• How many of you have had quality or infection control dictate to you what you should be telling the physician in a query?

• How many of you have had quality or infection control want you to question a physician’s documented diagnosis?

There are competing guidelines, rules, regulations, and definitions depending on which discipline you are from.

Agenda

• Multi-disciplinary collaboration

• Health information management: coding

• Infection control practitioners

• Infectious disease physicians

• Impact of HACs (Immediate/long-term: financial, P4P, VBP, etc.)

• Res Ipsa Loquitur

• CAUTI~FMEA

• CLABSI~PDSA

• Process flow maps

Multi-disciplinary Collaboration

CDI and reporting of patient safety data

Ensuring documentation is present to reduce or eliminate the inappropriate reporting of a healthcare-acquired condition (HAC)

Communication and Collaboration

Sharing data institutes and builds an environment for collaboration of internal partners and external customers.

Fiscal management Information systems Infection control Infectious disease physiciansEpidemiologist (PhD) Medical staff Risk management Material/supply managementNursing Quality managementPatient EducationCMO

Health information management,clinical documentation, etc.

COCOACOCOA CCharting OObvious CConditions OOn AArrival

Today’s focus will be on:

• CAUTI (catheter-associated urinary tract infections)

• CLABSI (central line–associated blood stream infections)

Public Report Cards:Where Do the DATA Come From?

Reporting of CMS’ HACs are identified via ICD-9-CM codes and modifiers as those conditions which are reasonably preventable and able to be identified via coded information.

The Infection Control HAI (healthcare-associated

infection) surveillance report is manually submitted and can include data not reported via ICD-9-CM codes such as diagnostic results, which may contradict what the provider documented.

Coding

BASED ON PROVIDER’S DOCUMENTED CLINICAL INTERPRETATION

Cannot code from diagnostic results

Must be documented by an approved provider

Must meet the criteria to be coded as a PDx/ODx and POA•“Y” yes POA ~ will be paid

•“N” not POA ~ will not be paid

•“U” not determinable if POA ~ will not be paid unless death or AMA

•“W” clinically not possible to determine POA ~ will be paid

CDC Infection Control Criterion:CAUTI

• Looks at diagnostic results, not clinical S&S

• Fever does not qualify as a symptom for UTI for IC reporting

• If catheter discontinued >48H, may not be reported as CAUTI

• Colony count may affect reporting

• If >2 species, may not be reported

• Not all organisms qualify as an IC CAUTI (e.g., candiduria)

Infectious Diseases Society of America: CAUTI

• Classic S&S that denote a symptomatic UTI are not always useful for catheterized patients; having said that, S&S such as FEVER, rigors, AMS, malaise, lethargy, pain, etc., with no other identifiable source may indicate a CAUTI

• Acknowledge gaps in our knowledge about CAUTI; burden for diagnosis is based on the CLINICAL JUDGEMENT of the treating physician

• Recognizes funguria (candiduria) as one of the most common pathogens for a nosocomial UTI

CDC Infection Control Criterion:CLABSI

• Use information from other sources besides provider documentation

• Select units and defined time frames • Can use microbiology reports, pharmacy

reports, communications from nursing staff, etc.• Must be an IC recognized pathogen (exclude

common skin contaminants); looks for laboratory confirmation

• Purulent phlebitis; +catheter tip; -BC; not a BSI per CDC

Infectious Diseases Society of America: CLABSI

• CLABSI can originate from the catheter (i.e., tip, hub, lumen); a positive peripheral BC is needed for Dx, but a positive peripheral BC can be delayed by 2H compared to from the line

• A CLABSI due to coagulase-negative staph frequently has FEVER alone but may also have catheter site redness. Coag-neg staph CLABSI may resolve with removal of the catheter alone and NO antibiotic treatment.

• Antibiotics should be initiated based on CLINICAL CLUES

Financial Impact

Immediate–AR/DNFC–Case-specific reimbursement

• If another MCC/CC documented in medical record, financial anticipated reimbursement may not be affected

Why the renewed interest from quality

directors?

Financial Impact

Long term– Hospital Inpatient Quality Reporting

Program required hospitals to begin submitting HAI data on Jan. 1, 2011; if a hospital does not participate, it will receive a 2% reduction in its annual CMS payment in 2012

– Marketing: HAC data will be found on CMS’ Hospital Compare website

– P4P, VBP, third-party contractuals

Theory of Res Ipsa Loquitur

The plaintiff will not need to prove the case, as the medical record will speak for itself by indicating the condition was not present on admission.

Document to avoid civil torte

ORHow much should the check be written for?

Impact: Transparency/Marketing

• Physician and hospital report cards– Clinical components may be defined by disease

• LOS

• Cost per case/CMI adjusted

• SOI

• ROM/RAM

• Age

• Complications

– P4P, VBP, etc.

Pay for Quality, Not Quantity

CAUTI: FMEA

Failure Modes and Effects Analysis: Even though we did not have an actual problem, we used this as an opportunity to be proactive in improving our processes by assessing for areas that could go wrong.

Infection control, quality, nursing, education, medical staff, material/supply management, information systems, risk, etc.

Inpatient: STROKE

DRG 63: HAC

Healthcare-acquired CAUTI

DRG 62: POA

CAUTI

present on admission

$7,875.78 $10,059.17

1981: CDC had 242 recommendations to prevent CAUTIs

2000: CDC estimates CAUTI may increase LOS by 1–4 days

CAUTI: COCOA Nursing POA Education

CLABSI: PDSA

Plan-Do-Study-ActA negative trending was identified in our outpatient dialysis unit Apply lessons learned to inpatient area

Patient, fiscal management, infection control, quality, nursing, education, medical staff, material/supply management, risk, etc.

CLABSI (CABSI): COCOA Nursing POA Education

Inpatient: Pneumonia d/t Klebsiella

DRG 179: HAC

Healthcare-acquired CLABSI

DRG 177: POA

CLABSI

present on admission

$7,687.81 $10,672.67

2002: CDC has 111 practices to prevent CLABSI

2000: CDC estimates a CLABSI increases LOS by 7–21 days

Process Flow Maps

Flow maps outlining our process for potential HAC investigation and the way we use it to keep our HAC DNFC (discharge not

final coded) down

Concurrent Process

CONCURRENT: Documentation specialists look at select charts concurrently for clarity and specificity in codeable documentation. If a suspected HAC is identified, the team is alerted.

CDN may query, if only POA clarification needed; otherwise, consultation with the team

Collaboration and CommunicationCollaboration and Communication

CONCURRENT POTENTIAL HAC

Documentation nurse discovers potential HACOR

Infection control nurse, care manager, etc. notifies documentation nurses of potential HAC

(phone/e-mail documentation)

Documentation nurse reviews chart for POA documentation per coding guidelines and notifies team as indicated; may query for POA

YES POA

Review completed, as NOT a HAC

NOT POA

Documentation nurse notifies quality, risk, and infection control, as appropriate

POAdetermination

made

COMMUNICATION

COORDINATION

Regardless Whether POA Is in Question

Quality and/or infection control may discuss

with physician regarding diagnosis of

CAUTI or CLABSI!

Post-Discharge Process

• POST-DISCHARGE: Each case (all-payer) is evaluated by a documentation specialist to determine whether it is an actual HAC or whether there are indications that the condition was POA. IC/quality also review chart, and IC/quality or CMO queries the physician if needed.

• CDN may query, if only POA clarification needed; otherwise, consultation with the team

• Collaboration and Communication

POST-DISCHARGE POTENTIAL HAC

HIM: Health information management notifies documentation nurse of potential HAC

Documentation nurse reviews chart for POA documentation per coding guidelines and, if not POA, notifies quality/infection control; cases are reviewed regardless of immediate payment implications

POAdetermination

made

YES POA

Not a HACReview

completed

NOT POA

Quality/infection control reviews chart; team discusses case; query written

Collaborative decision is

made: (goal 48 hours)

AGREE or AGREE to Disagree

HIM codes chart per

coding guidelines

BEFORE

FINAL

BILL

Coding Collaboration

We code only what is consistently documented in the medical record that meets coding guidelines for reporting PDx or ODx and POA

Most of the time these are queries for SOI/ROM

HIM coders and CDNs are integral parts of the POA/HAC team

Agree to Disagree

• Coding needs a provider’s consistent DOCUMENTED clinical interpretation of the significance of a result/condition in order to code and apply modifiers per coding guidelines.

• Infection control may use non-provider information and they look for laboratory confirmation, which may contradict what the treating physician documented.

Agree to Disagree

We know we will not always agree, so we have agreed to disagree. We know ahead of time what our data will be, and we are able to explain any discrepancies between the different reports.

All disciplines follow their rules and regulations for coding and reporting.

GOAL:

48 hours so that AR/DNFC is not delayed

Patient Safety

• Failing to connect the dots to realize an actual or potential problem exists (FMEA or PDSA)

• Failing to report the findings to all the appropriate team members

• Failing to do the follow-up and connect the dots with your stakeholders

• Failing to analyze what your data mean …

If you are not part of the solution, are you part of the conspiracy?

Ultimate Goals of HAC Communication and Collaboration

Risk reduction & prevention+ Performance excellence+ Financial stability

= PATIENT SAFETY and accurate HAC reporting

What We Have Discussed

• Differences between what can be coded and what IC reports as a HAI

• Multidisciplinary communication/collaboration

• Immediate and long-term impact of a HAC (financial, P4P, VBP, etc.)

• CAUTI ~ FMEA

• CLABSI ~ PDSA

• Res Ipsa Loquitur

• Process flow maps

We at Provena Health are fortunate to have two clinical documentation nurses who formerly worked as infection control nurses.

They were not able to be here today, but I want to acknowledge their extensive expertise and contributions to today’s session.

[email protected]@Provena.org

2011 HAC CMS Resources

• www.federalregister.gov Federal Register, Vol. 75, No. 157; Monday, August 16, 2010; Rules and Regulation (on pages 50084–50085 is the list of the HAC ICD-9-CM codes)

• www.cms.gov/HospitalAcqCond/downloads/HACFactsheet.pdf

• www.cms.gov/MLNProducts/downloads/wPOAFactSheet.pdf

National Healthcare Safety Network

“January 1, 2011, NHSN will be the tool used by facilities electing to participate in the CMS HAI IPPS Hospital Inpatient Quality Reporting Program, formerly known as Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU). As part of that program, central line–associated bloodstream infection (CLABSI) data from each facility’s adult and pediatric intensive care units and neonatal intensive care units will be reported to NHSN and shared with CMS. Each facility’s data will also be included in CMS’ Hospital Compare tool, which publicly reports hospital performance in a consistent and unified manner.”

www.cdc.gov/nhsn/cms-welcome.html

Additional CAUTI Information

• www.cdc.gov/HAI/ca_uti/uti.html

• www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf

• www.cdc.gov/nhsn/forms/57.114_UTI_BLANK.pdf

• www.journals.uchicago.edu/doi/pdf/10.1086/650482

Additional CLABSI Information

• www.cdc.gov/HAI/bsi/bsi.html

• www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf

• www.cdc.gov/nhsn/forms/57.108_PrimaryBSI_BLANK.pdf

• www.journals.uchicago.edu/doi/pdf/10.1086/320001

Any Questions?

Thank you