by Glenn Krauss
May 16th, 2018
DI's present-day Key Performance Indicators centered upon reimbursement do not truly reflect a meaningful account of performance in impacting the quality, completeness
- The medical record was first used by physicians to record their findings and actions and as a vehicle to communicate with other physicians who might care for the patient in the future.
- The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication.
- The clinical record should include the patient's story in as much detail as is required to retell the story.
Current CDI Processes-The Necessity for Reengineering
I submit to you that current processes of CDI focusing primarily upon the capture of CCs/MCCs and principal diagnosis optimization fails to address and achieve in any reasonable manner the purpose of clinical documentation as spelled out in the ACP’s Position Statement. As I have always maintained and still champion, reported diagnoses in the record must be surrounded and supported by accurate reporting and reflection of the clinical facts, clinical information
Progress notes are another problematic area where CDI should be focusing its efforts and energy as well beyond mere diagnosis capture that only impacts reimbursement. We are all too familiar with progress notes that lack purpose, substance
- Factually correct
- Temporally relevant (no future tense references to procedures already done)
- Concise (no fluff; just a concise statement of the facts)
- Devoid of plagiarism
- Analytic– (reflects thoughtful analysis of patient’s diagnosis, status, and treatment options)
- Reflective of collaboration (acknowledges collaboration with house staff, nursing, and other consultants)
Encompassing Key Performance Indicator for Progress Notes
A recent article certainly worthy of reading by all CDI specialists recently published in the January 2018 Journal of Hospital Medicine is titled A Prescription for Note Bloat; An Effective Progress Note Template. The article outlines the results of a quality improvement study carried out at four major academic healthcare institutions: University of California Los Angeles (UCLA), University of California San Francisco (UCSF), University of California San Diego (UCSD), and University of Iowa. This clinical documentation quality improvement study combined brief educational conferences directed at house staff and attendings with the implementation of an electronic progress note template. The goal of the study was to determine if progress note quality can positively be impacted and achieved through brief interventions and utilization progress note templates. Note quality was measured using a general impression score; the Validated Physician Documentation Quality Instrument, 9 item version; and a competency questionnaire. What stood out and immediately came to mind was the applicableness of the Physician Documentation Quality Instrument, 9 item version as an instrument the CDI profession could potentially use as a Key Performance Indicator measuring our success in achieving sustainable improvement in clinical documentation. Here is the list of items in the instrument:
- Up-to-date: The note contains the most recent test results and recommendations.
- Accurate: The note is true. It is free of incorrect information.
- Thorough: The note is complete and documents all of the issues of importance to the patient.
- Useful: The note is extremely relevant, providing valuable information and/or analysis.
- Organized: The note is well formed and structured in a way that helps the reader understand the patient’s clinical course.
- Comprehensible: The note is clear, without ambiguity or sections that are difficult to understand.
- Succinct: The note is brief, to the point, and without redundancy.
- Synthesized: The note reflects the author’s understanding of the patient’s status and ability to provide a plan of care.
- Internally consistent: No part of the note ignores or contradicts any other part.
For scoring, one can assign 12.5 points for each item for a total of 100 points with
Time to Rethink Our KPIs
In conclusion, there are numerous Key Performance Indicators that can possibly be used to more accurately reflect and report the achieved successes of CDI in affecting positive change in the quality and completeness of documentation including progress notes. Good documentation is a fundamental component of high-quality care. The profession alludes to the fact and wants to take credit for improving the reported quality of care in the hospital. Let’s revisit our processes of CDI in the interest of actually improving the quality of care through achievement of consistently sound principles of clinical documentation to complement our efforts at securing diagnoses and optimal reimbursement. Optimal reimbursement is not rooted in longevity and sustainability without optimal clinical
About the Author
Glenn Krauss is a longtime Revenue Cycle Professional with progressive hands