A 900+-bed acute care hospital operating within a major academic medical system was identified in Vizient's annual Quality & Accountability Study* as having poor performance measures in mortality and composite patient safety indicators (PSI). The percentage of hospital-acquired conditions at this facility was significantly higher than that at other institutions in the study. Clearly the situation required immediate remediation to improve patient outcomes and to stop the reduction in payment, which resulted from underperformance.
* Vizient is an alliance of the nation’s leading academic medical centers (AMCs). Its annual Quality & Accountability Study ranks AMCs on measures of mortality, effectiveness, safety, equity, patient centeredness, and efficiency.
The facility administrators sought counsel on quality improvement from Axea Solutions. Together, the hospital and Axea Solutions implemented an enhanced process of clinical documentation improvement (CDI), addressing documentation matters related to PSI. The use of Axea’s PSI/HAC database allowed the client to track and to trend the occurrences of hospital-acquired conditions, the physicians treating these conditions, and ultimately, the number of occurrences overturned after following the process described here. Most importantly, this tracking was used for education of coders, quality improvement analysts and physicians.
Process for PSI Quality Improvement
1. If a record is coded with a condition known as a PSI, the record is reviewed by a coding supervisor. If the supervisor agrees with the code assignment, the record is forwarded to a performance improvement analyst for review.
2. If a disagreement presents at that juncture, the case is discussed by both the coder and the analyst.
3. Further input is solicited from the physician advocate of the service line under review or from the chief quality officer at the hospital.
4. At that point, the case is discussed with the senior coder and analyst and a final determination is made.
This was an intensive process and required complete commitment and participation from both teams. With Axea’s support implementing the new review process, the facility improved its ranking from the bottom 50% to the top 25% in the subsequent Quality & Accountability Study's observed-to-expected (O:E) mortality index.
The composite score of patient safety indicators improved significantly – the facility’s ranking increased from 75 out of 113 to 13 out of 116 hospitals in a composite score of patient safety indicators. The facility was awarded four stars by Vizient and received the designation of "Rising Star" for its ascent in the annual rankings by more than 20 spots in a 12-month period.
The work that began years ago has delivered lasting change within the facility, improving accountability across clinical and nonclinical teams for improved patient safety and quality of care. Upon receiving the 2016 inaugural Innovation Excellence Award from Vizient, the accepting representative acknowledged, ”we are constantly looking for new, effective ways to help patients, and the best way to measure that is by keeping an eye on our quality data."
Susan Gatehouse, CEO, Axea Solutions, offers these takeaway lessons.
• Buy-in is everything. Most people and institutions are not comfortable with change. It's human nature. However, when human lives are on the line, people react differently. This facility's administration and staff made the decision to do whatever it took to improve outcomes for their patients and to advance their ability to provide quality care.
• Hard numbers help. Without the results of the analysis provided by Vizient, it would likely have taken longer for this facility to address the areas of weakness identified. Good data is important for initiating change.
• Change is possible. Even when the hard data is not what you want to see and the task of turning it around is daunting, systems can be repaired. It is important to realistically assess what is not working, identify where improvement is necessary, and begin the process.
• Relationship-building is crucial. Fostering an atmosphere of open communication and respect during times of transition is paramount. Axea's knowledge of the challenges that coders, quality assurance analysts, and clinicians encounter on a daily basis allows us to build bridges and to eliminate divisiveness.
• Get help. Administrators can often become overburdened and time-crunched. Seeking outside counsel from experts in process improvement provides that critical stepping-back view, and allows for change to unfold.
• Know that you're not alone. Even if your institution is not a medical center nor exposed to the public scrutiny of a study like the one described here, it will begin being benchmarked to the same measures. This era of health care reimbursement reform affects all of us. Let's work together to maximize effectiveness, safety, patient centeredness, and efficiency for our bottom lines and our patients' wellbeing.
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