1. The Challenge: To Be the Best The Need for A Model Observations In the 3rd quarter of 2007 this facility’s mortality index was 37% higher than expected, where the UHC top 10 were approximately 20% better than expected. The medical center’s physician leadership implemented a program that quarter to capture actual severity of illness. The marked improvement in mortality index was due, primarily, to a more accurate representation of the actual acuity of inpatients at the facility. The medical staff is now able to demonstrate the actual quality of care they are providing, particularly in complex medical and surgical cases. Clinical Integration: Improving Quality Measures Paul Weygandt, MD, JD, MPH, MBA J. A. Thomas & Associates Copyright Information Here Perception = Measured Quality A New Role to Improve Care In November, 1999, the Institute of Medicine released its sentinel report “To Err Is Human: Building a Safer Health System.” The medical community and the public were both shocked and appalled by the reported 98,000 preventable deaths each year in US hospitals. Many hospital quality and safety initiatives were implemented in response. Physician leaders have also increasingly been held accountable for improved measured clinical outcomes. As early as 2003, I became aware of the substantial impact of clinical documentation improvement on severity adjusted clinical outcomes. At my hospital, we observed dramatic improvements in such outcome measures shortly after implementing a clinical documentation improvement program. Clearly this was primarily due to capturing correct DRG assignment, indicating the appropriate severity of illness of the patients we treated. From a broader perspective, however, we struggled to improve other parameters of patient safety and quality. Entities such as the Joint Commission began to focus on preventable errors, sentinel events, near misses, and the like. These events were studied in a retrospective manner through “root cause analysis” and other techniques with the intent of avoiding future events. What became apparent to many physicians “in the trenches” was that hospital care has become increasingly fragmented. Rarely is a patient managed by only one physician. We also have other disciplines actively involved in care such as dieticians, physical therapists, nurses, and non-physician practitioners. Put bluntly, we do a poor job of communicating. One solution almost universally applauded about 10 years ago was the adoption of the electronic medical record (EMR), the panacea for information exchange. Despite our early enthusiasm, reality has been much less rewarding than anticipated. In fact, many physicians have experienced increased fragmentation (non-integration) of the clinical record with the advent of the EMR. It is a rarity for physicians to actually review electronic nurses, dietary, PT, OT or other notes. Yet frequently potential patient safety and quality issues are identified in these ancillary notes – information that can and will be used against physicians and hospitals by plaintiff’s attorneys. Clinical Integration is one of the most exciting developments in the pursuit of quality over the past decade. From my perspective, one of the most significant limitations on true improvement in patient safety and quality has been the inability to concurrently identify high risk situations and intervene proactively. We should not respond to medical errors, but rather, prevent them. A new role is emerging in hospital practice, that of the clinical integration specialist, typically an experienced med-surg, ICU, ED or similar nurse with documentation and coding skills with additional attributes enabling a more direct impact on patient safety and quality initiatives. By integrating the clinical integration specialist into the clinical team, we have an individual who, on a real-time basis, can review risk factors, propensities, apparent but undocumented clinical conditions, and improve communication (integration) between caregivers. The added ability to assist the physician in determining “medical necessity” for inpatient care decreases physician workload and enhances accuracy of status determinations. Current Physician Leadership Challenges Place Graphic Here Observation This facility within approximately a 2 year period moved from essentially the worst performance in the UHC to the best. The patient population stayed about the same and services and service providers remained essentially stable. The marked improvement in mortality index was due, primarily, to a more accurate representation of the actual acuity of inpatients at the facility. Observation A teaching institution was profiled in the news media based upon state quality scores. The actual mortality in 2004 substantially exceeded expected mortality, resulting in local headlines critical of the quality of care provided. The medical leadership selected a two-tiered approach; improving the actual quality of care delivered and also capturing the severity of illness more accurately through improved physician documentation. Mortality index showed an almost linear decrease moving from 8% higher than predicted mortality to 28% lower than expected. QUALITY Does your hospital demonstrate the quality (objective measurement) expected by your board, community, insurers, physicians, and others? EMR / EHR The physician is accountable for all information in the medical record. What physician has time to read all PT, OT, RT, and other notes in the EMR? Are physicians aware of Patient Safety Indicators as they happen? RACs, MACs, and other ATTACKs QIOs, RACs, MACs and others are challenging Observation / Admission status, Medical Necessity, Correct Coding, etc., and are increasingly aggressive A new challenge - medical reviewers are disputing well documented diagnoses of treating physicians to downcode records The Clinical Integration Solution The Clinical Integration Specialist Reviews the entire EMR to assure communication among the clinical team Supports accuracy and specificity of physician documentation, accurate core measure and patient safety indicator capture, and correct status determination Assures regulatory compliance The Challenge: To Be the Best No State Data