1. Real Time Abstraction A Multidisciplinary Approach

2. Multidisciplinary Team
Clinical Care Excellence Team
Nurse Manager
Staff Nurse
Charge Nurse
Abstractors/Coders
Pharmacy
Social Worker/Utilization Review
Respiratory
Quality Risk Manager
Admission Nurse/ Infection Control
Surgical Team Member
Registration/Insurance Verifier

3. Admission Nurse Role Patient Placement/Eligibility
Completes Initial Interview
Complete skin assessment
Review all Present on Admission concerns
Initiate the CMS indicators when appropriate
Note and communicate risk for HAC
Review all admissions completed on the off shifts for proper documentation
Medication reconciliation at Admission
Completes Admission worksheet and reports CMS indicator issues to staff nurse
Report admitting diagnosis to coders
Fax admission checklist to Medical Record

4. Charge Nurse Role Attend daily Multidisciplinary Meeting at 10:00am
Report on tentative discharge dates.
Monitor Staff Nurse documentation for CMS compliance.
Ensure follow through by staff nurses of items presented at Multidisciplinary Meeting.
Staff nurse to report pending issues to charge nurse .
Communicates if needed with physicians to ensure compliance with CMS indicators.
Reviews daily census reports with History and daily vitals of all patients on floor.
Maintains White message board in break room daily

5. Staff Nurse Clinical Time with patient
Reports on patient to Multidisciplinary team at 10:00am.
Clinical documentation
Review Admission Nurse Checklist and follow-up on pending issues that have been identified.
Obtains physician orders to comply with CMS indicators using standing orders or evidence based order sets.
Views message board-post-it in EMR for issues from abstractor. Place action taken with date and time.
Follows up on actions needed from message board in EMR on documentation required and or seeks physician orders to comply with CMS indicators.
Rounds on patient

6. Abstractors
Daily review of inpatients EMR and surgical schedule and ensure compliance with CMS Indicators.
Attend daily Multidisciplinary meeting at 10:00 and report and follow-up on pending documentation issues.
Comment in EMR on message board –Post-it documentation issues.
Report any significant changes in care plan or diagnosis to coders and multidisplinary team.
outstanding issues to nursing supervisor/charge.

7. Coder
Assign a working DRG at admission based on admitting diagnosis and history and physical.
Attend Multidisciplinary Meetings, present preliminary coding of cases to abstractors.
Post changes to DRG through review of chart or through communication with abstractor in EMR through Post-it.

8. Pharmacist
Medication Reconciliation Review at Admission, transfers and discharge
Attend Multidisciplinary Meetings
Communicate medication changes with physicians that are needed to meet CMS indicator medication requirements.

9. Social Worker/ Utilization Review
Social Issues and Placement
Attend all Multidisciplinary Meetings
Ensure documentation of Care Conferences in patient chart.
Confirm and communicate insurance data and eligibility.
Report Insurance Status
Appropriate use of level of care to ensure best reimbursement.
Assign tentative discharge date and relays to team.
Help team achieve discharge date

10. Multidisciplinary Team Meetings

11. Admission Checklist from Admission Nurse Program SAM-MC

12. COMMUNICATION
Communication will be the Key to Success

13. Communication Standardize communication
Use SBAR and standarized taxonomy
S- situation; whats the problem
B- background; the context, objective data, the numbers
Assessment: whats the problem?
Recommendation; what do we need to do and when? How are we going to fix it? What is needed from physician

14. COMMUNICATION Saves time for physicians, patients and staff
Clear way to communicate
Avoid staff and physician frustration
Eliminate unnecessary information
(hear-say, and opinions)

15. SBAR

16. COMMUNICATION
Display results of CMS Indicator Scores and publically reported measures in all break rooms so all staff aware of our standing and update monthly.
Continued education on CMS Indicators and future indicators.

17. Result Postings

18. Teamwork
Enhance performance and ensure the best quality of care by team
All of team on same page
No idea or suggestion discouraged
Every team member has a voice
Brainstorm to achieve best outcome.
Administrative support of team
Include patient concerns

19. Goal
Quality Care and the best evidence based practices given for our patients.
100% Compliance with CMS Indicators
Obtain highest level of reimbursement
Achieve above State and National scores on publically reported measures.
Patient, Physician, and Staff Satisfaction

20. Work In Progress
Bi-Weekly CMS Fallout meeting with nursing supervisors/Charge abstractors and quality.
Keep identify what is working and not working or barriers to compliance.
Hospitalist added to multidisciplinary daily meeting.
Hospitalist follow-up with attending on issues identified at meeting.
Address fallout's real-time with staff
Continue letters to physicians on fallout's.
CPOE/EBOS

21. Where are we now.

22. Thank You For your time and attention