ACDIS day3-14 track4-11 pres 0517-Armistead …...– SOP for accurate review of cases – Education of providers on clinical/coding chasm 21 Process Improvements PSI review committee

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Vaughn Matacale, MD, Director, CDAPNiti Armistead, MD, Medical Director of Quality

Vidant HealthGreenville, NC

CDI and Quality: A Team‐Based Approach for PSI Management

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Discuss concepts and strategies for Patient Safety Indicator (PSI) management

– Determine team composition for a PSI committee

– Describe how to apply a broad‐based team approach to PSI reviews and management

– Analyze the impact a team approach has on PSI rates

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Introduction and Overview

2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Vidant Health

• Eight hospitals (three CAHs)• 1,447 beds• Affiliated medical school• Over 30 IP coders and 15 CDSs• Over 36 quality staff

• 11,899 employees• Over 1,000 providers• 64,388 admissions• 46,544 surgeries• Five physician advisors

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AHRQ Patient Safety Indicators (PSIs)

• What are PSIs? – A set of indicators providing information on potential in‐hospital

complications and adverse events following surgeries, procedures, and childbirth

– Coding‐driven; administrative data

• How are PSIs meant to be used?– Identify potential adverse events that need further study

– Drive system improvement in areas with gaps in care

• Direct link to AHRQ specifications – http://www.qualityindicators.ahrq.gov/Modules/PSI_TechSpec_IC

D10_v60.aspx

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CMS Payment Reform Initiatives

2011 2012 2013 2014 2015 2016 2017

Value‐Based Purchasing (VBP) Up to 2% Penalty/Bonus Applied to Base Operating DRG

Hospital Readmissions Reduction Program (HRRP) 3% Penalty Applied to Base Operating DRG

Hospital Acquired Conditions (HAC) 1% Penalty Applied to Operating Payment

1%

1.25%

1.5% 2%

1.75%

3%

2%

1%

1%

3%

3%

1%

1%


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VBP: FY 2017

Measure ID NQS‐Based Domain

AMI‐7a Clinical Care – Process

IMM‐2 Clinical Care – Process

PC‐01 “NEW” Clinical Care – Process

Mort‐30‐AMI Clinical Care – Outcomes

Mort‐30‐HF Clinical Care – Outcomes

Mort‐30‐PN Clinical Care – Outcomes

HCAHPS Patient and Caregiver Centered Experience of Care / Care Coordination

CAUTI Safety

CLABSI Safety

PSI‐90 Safety

SSI Safety

MRSA “NEW” Safety

C. Diff “NEW” Safety

MSPB‐1 Efficiency and Cost Reduction

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VBP: FY 2018

25%

25%25%

25%

FY 2018

Clinical Care

Patient & Caregiver Experience

Safety

Efficiency and Cost Reduction

Measure ID NQS‐Based Domain

Mort‐30‐AMI Clinical Care

Mort‐30‐HF Clinical Care

Mort‐30‐PN Clinical Care

HCAHPSPatient and Caregiver Centered Experience of Care / Care Coordination

CAUTI Safety

CLABSI Safety

PSI‐90 Safety

SSI Safety

MRSA Safety

C. Diff Safety

PC‐01 (Moved) Safety

MSPB‐1 Efficiency and Cost Reduction

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Public Reporting


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Quality Ranking vs. Peers

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2008 2010 2012 2014 2016

Quality metrics

• Mortality• Safety• Efficiency• Effectiveness• Patient centeredness

• Equity

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Recent Changes With AHRQ PSI 90

• Name change: Patient Safety and Adverse Events Composite (Modified PSI 90)

• Component weights have significantly changed and now incorporate harm associated with the event

PSI 90 v5.0 Modified PSI 90 v6.0

PSI 15 Accidental Puncture = 43.9% PSI 11 Postop Respiratory Failure = 30.5%

PSI 12 PE/DVT = 33.8% PSI 13 Postop Sepsis = 21.6%

PSI 12 Periop PE/DVT = 20.9%

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PSI 90: Changing Weights …

PSI Indicator V5.0 V6.0 Difference

PSI 03 Pressure Ulcer .033 .060 81.3%

PSI 06 Iatrogenic Pneumothorax .075 .053 ‐28.7%

PSI 07 CVC‐Related Blood Stream Infection .038 ‐‐‐ N/A

PSI 08 In‐Hospital Fall w/Hip Fracture .002 .010 462.2%

PSI 09 Periop Hemorrhage and Hematoma ‐‐‐ .085 N/A

PSI 10 Postop AKI ‐‐‐ .041 N/A

PSI 11 Postop Respiratory Failure ‐‐‐ .305 N/A

PSI 12 Periop PE and DVT .338 .209 ‐38.2%

PSI 13 Postop Sepsis .057 .216 277.0%

PSI 14 Postop Wound Dehiscence .018 .013 ‐27.1%

PSI 15 Unrecog Abdom/Pelv Acc Punc/Lac .439 .007 ‐98.4%

https://www.qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ_v2.pdf


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Change in Coding Guidelines Impacting AHRQ Exclusion

PSI 9

• New codes for seroma!! No longer maps to hematoma.

• AHA Coding Clinic 2016, Q1, p. 14. For bleeding that is associated with a drug as part of anticoagulation therapy, assign code D68.32, Hemorrhage disorder due to circulating anticoagulants.

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Big‐Impact Changes With AHRQ V6.0

PSI 13

• No longer excludes diagnosis or procedure codes for immunocompromised state in denominator

• No longer excludes cancer diagnosis codes in denominator

• No longer excludes LOS less than 4 days in denominator

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Big‐Impact Changes With AHRQ V6.0

PSI 15

• New name: Unrecognized Abdominopelvic Accidental Puncture or Laceration Rate

• Accidental puncture or laceration of the abdomen or pelvis that requires a second abdominopelvic operation one or more days after the index abdominopelvic operation


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PSI Review Process: Old Approach

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Old Approach

• August 2013: Office of Quality (OOQ) developed four initial pre‐billing work queues (WQ) in EHR (6, 9, 11, 15)

– Manual; multiple iterations to ensure case accuracy

– Communication: To coding on possible query opportunity and/or coding opportunity

– Quarterly meetings between OOQ and coding

• February 2014: Added PSI 13 & 14 to the WQ

• July 2014: Complication query standardized

• January 2015: PSI 3 added (high impact on Leapfrog)

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Limitations

• Inefficiencies

• Inconsistent communication

• Non‐standard approach between quality, coding, physician advisor

– High variability

• Lack of medical staff involvement

• Lack of understanding of opportunities around PSIs, clinical care, and documentation/coding


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Restructuring

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Restructuring: Summer 2015

• Involve key stakeholders

– Quality medical director and staff, CDI, coder/auditor, physician advisor, physicians

• Population

– Patients identified with PSI flag populating into quality work queue

• Goals

– Understand AHRQ specs to affirm inclusion and exclusion criteria

– Review for alternate compliant non‐PSI coding options

– SOP for accurate review of cases

– Education of providers on clinical/coding chasm

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Process Improvements

PSI review committee– Key stakeholders:

• Three surgeons with varying specialty (general/trauma surgery, surgical oncology, and procedural cardiology)

• Medical director for office of quality• Quality nurse specialist and quality specialist• Clinical documentation improvement specialist and physician advisor

– Committee goals• Notification and education to providers• Identify documentation vs. clinical care opportunity and QI concern

• Drive improvement in safety and quality by identifying system issues


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PSI Algorithm

HIMS and quality staff review the case simultaneously from the same work queue. Examined for inclusion/exclusion codes. If a case is validated for PSI, the DNB is removed and bill is released. All identified PSIs are routed through the PSI Review Committee, and the provider is notified of a PSI tag. All QI concerns are sent to peer review.

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PSI Algorithm

If the case is not released on exclusion or confirmation of a PSI, then a more detailed review Is undertaken. The case is reviewed for documentation and coding opportunities, or to identify need for further clarification from the provider. This may result in a coding change, further review by coding experts (PA, CDI, lead auditor), or a query to the provider to clarify the issue.


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PSI Algorithm

The key here is that the decision is placed into the provider’s hands. The provider determines whether the event was a PSI (complication) or not. This is the final step for the process of determination; after this, the chart is released for billing. All identified PSIs are routed through the PSI Review Committee, and the provider is notified of a PSI tag. QI concerns identified are sent to peer review.

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PSI Reviews Dashboard Example

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Linkages Post‐Review

• Actions related to PSI review process:

– Peer review for single case

– Peer review for trend

– Refer cases to existing PI teams

– Recommend creation of new PI team

– Nursing peer review

– Ongoing staff education

• Provider notification in EHR inbox using standard template and education


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Provider Notification and FAQFrequently Asked Questions Answers

What are Patient Safety Indicators (PSIs)?

PSIs were developed by The Agency for Healthcare Research and Quality (AHRQ) to provide information on potential in‐hospital complications and adverse events following surgeries, procedures, and childbirth. Hospital discharge admission data is put through software with specific inclusion and exclusion criteria to determine incidence of adverse events and complication

Why is it important? PSIs are used as a measure of safety of care provided by hospitals and providers. Since these reported complication rates impact reputation, reimbursement, and where patients choose to go for needed procedures, VMC medical staff members requested direct and timely feedback on individual performance. The overarching goal of PSI reporting is to recognize unintended adverse events, learn from them, and take action to prevent future events when possible.

Why am I being notified? After an event is systematically reviewed by Quality/HIMS staff and is determined to meet the inclusion criteria of AHRQ specifications, providers are notified through secure EHR message. The purpose of the notification is provide physicians opportunity for practice‐based learning and to participatein system‐based improvement efforts.

Are all adverse events that occur during or following surgery classified as complications?

No. There must be a cause‐and‐effect relationship between the care providedand the condition, and an indication in the documentation that it is a complication. If there is vague or conflicting documentation the provider is queried for clarification.

What about cases where occurrences are unavoidable?

It is important to differentiate between occurrences that are inherent to the procedure/unavoidable and those that are an accidental complication. This iimportant to avoid incorrect reporting of a complication. Events that may, in the clinical judgment of the provider, be routinely expected or inherent to thnature or difficulty of the procedure or the patient’s anatomy/condition mushave clear documented reasons of unavoidability.

Does it matter if an occurrence is clinically significant or not?

Only events deemed to be clinically significant by the provider are coded as acomplication. Some indications of clinical significance may include but not limited to: increased length of stay, required blood transfusion, surgical repareturn to operating room for bleeding, etc.

How can I improve the accuracy of my documentation?

Make sure documentation is clear and consistent in the medical record and respond promptly and completely to all requests for documentation clarification. Be aware that the use of term “complication” may suggest a potential reportable event. Always make sure to document fully and to clearindicate inherent vs. accidental occurrences. In your operative note, please be specific with laterality, depth, and precise location of complication and necessary repair to accurately comply with ICD‐10 coding.

Example terms for true complication and non‐accidental complication

True Complication Non‐accidental Complication

Inadvertent, inadvertently

Complication, complication by

Accidental, accidently Unintended, unintentionally

Unexpected, unexpectedly

Iatrogenic

To facilitate

Necessary

Required Intentional

Intended

Inherent

Integral Routinely expected

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Clinical Examples With Query/Coding Impact

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Case Example #1: PSI 11 Postop Respiratory Failure

Quality review/clinical:

Pt with kyphoscoliosis. Underwent spinal fusion from T4 to the pelvis. Hemovac x 3 and chest tube. Kept intubated after surgery.

Left on vent postoperatively. Needed MRI next morning. Extubated POD#2.

Documentation: "Postop respiratory insufficiency" and also “respiratory failure.” “Stable on vent.”

Coded as postop resp failure.

Can we query to clarify if patient had respiratory failure or respiratory insufficiency?

Coding review:

Acute postop respiratory failure was coded. Conflicting documentation is present; send a query to clarify the condition.

MD query response:

“She did not have respiratory failure. She was kept intubated due to the magnitude of the procedure.”


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Case Example #1: PSI 11 Lessons Learned

• Staged procedures, re‐intubation code

• Complexity of procedure

• Remove postop term from vocabulary—can create false association

• Prehab

• Preoperative evaluation/case selection

• Admit status matters (elective only)

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Case Example #2: PSI 9 Postop Hemorrhage/Hematoma


Patient admitted with acute CHF and atrial fibrillation on anticoagulation. EF 20%. Needed pacemaker upgrade, placed on therapeutic Lovenox post procedure. Developed a hematoma of pacemaker pocket.

Can a query for hemorrhage due to external anticoagulant be issued?

Coding review:

Query the physician to see if Lovenox contributed to the cause of the bleeding to add D68.32 as an exclusion.

Query response:

The bleeding was related to the anticoagulation.

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Case Example #3: PSI 9 Postop Hemorrhage/Hematoma

Clinical summary:

Pt admitted for anterior cervical fusion for HNP with cord compression.

Complicated postop course included DVT followed by anticoagulation followed by hematoma.

Physician advisor review:

Surgery on 1/26/16. Pt developed DVT and IVC filter placed. Later started on therapeutic Lovenox. Discontinued on 2/10 due to hematoma. Consider code D6832 (hemorrhagic disorder due to extrinsic circulating anticoagulants).

PSI committee review:

“I found lack of appropriate chemoprophylaxis after surgery. This resulted in a VTE, then full anticoagulation, then bleeding at the operative site. The patient was anti‐coagulated at the time this event occurred and feel bleeding was due to anticoagulation and not a postop complication. Is there an appropriate anticoagulation code that can be added”?

Coding review:

Documentation supports bleeding due to Lovenox. Code D6832 has been added.


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Case Examples #2 and #3: PSI 9 Lessons Learned

• Coding Clinic update January 2016 re: Category D68 Coagulation defect can be used when bleeding associated with anticoagulation therapy

• Bleeding as expected outcome of medication needs to be documented in MD notes

• Cases when hematoma is expected/inherent should reflect that in the documentation

• Clinical significance of hematoma or bleeding

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Case Example #4: PSI 12 Postop DVT/PE


Pt presented to OSH and sustained STEMI and cardiac arrest. Prolonged CPR pH 6.8. Transferred and received stent, CT anoxic brain. On vent, balloon pump, pressors. LE US ordered to eval for DVT was +.

Quality: Was the DVT POA?

Coding:

Initially coded as POA of N. Query the physician to determine POA status of the DVT.

Query response: POA status clinically indeterminable. POA status changed from N to W.

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• Significance of POA

• Flawed metric

• Nursing peer review

• New charter PI team for DVT/PE


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Case Example #5: PSI 13 Postoperative Sepsis


Patient underwent TAVR, sustained esophageal perforation, and had esophageal stent placed. Postop developed leukocytosis 17K termed “stress leukocytosis.” Vitals stable, no fever. Started on antibiotics and antifungals. Follow‐up CT negative for leak or pneumonia. All cultures negative.

Sepsis documented in MD progress notes x 3.

Sepsis picked up by coder and coded.


The patient did not meet criteria for sepsis. Leukocytosis stated as due to stress from surgery; no other criteria met. Can the sepsis code be removed?

Coding review:

Sepsis was documented in three notes, then documentation changed the term to leukocytosis. Sepsis not contained in the d/c summary. Appeared to be ruled out. Sepsis code removed.

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• Several eyes on sepsis criteria and collaboration with coding

• Clinical validation is warranted

• Thorough preoperative evaluation/case selection

• Admit status matters (elective only)

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Case Example #6: PSI 14 Wound Dehiscence


Complex colon resection. Required trach and PEG. Drainage noted from abdominal wound so 2 staples removed and wound packed. During OR visit for trach/PEG the abdominal wound was re‐closed.

Coded as Repair of abdominal wall.


“This is not wound dehiscence as fascia was intact. Evaluate for alternate code as this is not really repair of abdominal wall.”

The wound was intentionally opened. Review of procedure note shows only staples replaced to skin. No subcutaneous or deep sutures. Is repair of abdominal wall the correct code?

Coding review:

The procedure code should be repair of skin since the only area addressed was the skin. Code changed.


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• Depth of repair, tissues involved

• Important to capture immunocompromised state

• Abdominal wall is general anatomical region and is not reported when additional info regarding body part involved in procedure (i.e., use the most specific procedure code)

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Case Example #7: PSI 15 Accidental Puncture or Laceration


Pt with 11 cm pelvic mass adherent to pelvic wall and sigmoid colon. Underwent resection with extensive lysis of adhesions of over 2 hours. General surgery requested to assist to repair deserosalization of the rectosigmoid.

Coded as accidental puncture or laceration.


Extensive adhesions, 2 hours of lysis, dense adhesion between mass and rectosigmoid colon, 4x4 area of deserosalization in area where mass was taken off.

Was this inherent or unavoidable? Can we query?

MD query response:

An unavoidable occurrence inherent to the surgical procedure. The colon was densely adherent to the pelvic mass throughout and I would consider it unavoidable given the extent of her scar tissue and endometriosis.

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• Clinical significance

• What is inherent or unavoidable?

• Educate procedural staff on terminology to make events clear for coding

– Inherent, unavoidable, necessary, sacrificed

– Inadvertent, accidental, unintentional


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Results and Summary

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AHRQ PSI Summary

AHRQPatient Safety

IndicatorCalendar Year 2014 Calendar Year 2015 Calendar Year 2016

PSI 3: Pressure Ulcer 3 1 5

PSI 6: Iatrogenic Pneumothorax

9 5 4

PSI 9: Perioperative Hemorrhage/ Hematoma 50 33 19

PSI 11: Postoperative Respiratory Failure

43 30 24

PSI 12: Postop PE/DVT 55 70 44

PSI 13: Postop Sepsis 13 7 13

PSI 14: Wound Dehiscence

9 3 0

PSI 15: AccidentalPuncture/Laceration

58 44 25

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AHRQ PSI 90 Trends

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

0.45

0.50

0.55

0.60

PSI 90 Rate (O:E)

PSI 90 Rate Linear (PSI 90 Rate)


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Key Points for PSI Management

• COLLABORATION AND EDUCATION

• Concurrent reviews by auditors and quality reviewers

– Real‐time dialogue

– Mutual education on inclusions, exclusions, coding concepts and guidelines

– Deep support within each department for PSI reviews


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Key Points for PSI Management

• PSI committee

– CDI, auditor, physician advisor, quality reviewers, quality medical director, and ACTIVE MEDICAL STAFF LEADERS

– Open dialogue with all subject matter experts in one place at the same time

– Rapid dissemination of concepts to medical staff

– Cases reviewed by multiple parties before meetings

– Quality of care issues identified

• Medical staff peer review

• Nursing peer review

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Thank you. Questions?

[email protected]@vidanthealth.com

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.


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Documents

ACDIS day3-14 track4-11 pres 0517-Armistead …...– SOP for accurate review of cases – Education of providers on clinical/coding chasm 21 Process Improvements PSI review committee