The Changing Role of Documentation October 18, 2007

Todays Topic The way it used to be The way it is now Patient safety Performance improvement through public reporting CMS annual payment update Patient care satisfaction

Reliable Documentation An 80 or 90 percent success rate might sound good to an institution, but from the patients standpoint its unacceptable, says Resar. A hospital wants to know how well its doing for its entire patient population. The patient wants to know how well youre doing by him or her. For the individual patient, reliability is an all-or-none matter, says Resar. If the right care has five elements and the medical team accomplishes all five only 90 percent of the time, thats 100 percent failure for each of the 10 percent of patients who dont get all the recommended care. There is no partial credit for reliability. (For a recent discussion of All-or-None Measurement," see the March 2006 article by Berwick and Nolan.) Of course, even when human beings do their very best, they dont always succeed, so Resar and other faculty leading an IHI Learning and Innovation Community have developed a framework for improved reliability based on industrial principles of standardization. It begins with protocols of care that are evidence- based and widely agreed-upon, says Fran Griffin, RRT, MPA, who is the Director for Designing for Reliability in Clinical Practices as part of IHIs IMPACT Program.

Todays Goals & Objectives Insight from best practice hospitals Objectives Learn about successful documentation processes Understand how to address gaps in the documentation process Take away practical ideas for change

Process Flowchart

Documentation Process Panel of 3 hospitals tell their story Panel discussion of their process to assure reliable documentation What steps are used consistently to provide accurate and reliable documentation What tools secure the documentation is in the chart

Documentation Process How they handle variations in documentation How they got everyone (physicians, nurses, ancillary support staff) singing the same tune Why team work is essential

Questions One problem that we face is working with physicians on improving their documentation. How can we encourage them to be more helpful? Any ideas?

Questions We do computerized documentation using flowcharts and electronic forms. We have piloted "Charting by Exception" in our obstetrical area. We would like one of the discussions to be on "Charting by Exceptions". We did contact JCAHO and they said that it can be used. My thoughts only.

To Consider Does the chart forms and format reflect the core measurement requirements? Do the physicians understand why documentation and the core measures reflect the evidence-based guidelines? Does the abstraction staff understand the complete definitions of all data elements for the core performance measures?

Contact Information: MetaStar, Inc Landmark Place Madison, WI (608) This material was prepared by MetaStar, the Medicare Quality Improvement Organization for Wisconsin, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-WI-INP