With the Centers for Medicare & Medicaid Services and The Joint Commission increasing documentation scrutiny, and all major payers moving toward using core measure results to benchmark and conduct contract negotiations, providers must consider how clinical documentation improvement (CDI) can positively impact quality.  Although CDI and the engagement of clinical documentation specialists (CDSs) can significantly improve quality, how does a hospital layer on core measure and patient safety monitoring efficiently?

Sanford Medical Center, located in Bismarck, North Dakota, knows how.  In October 2013, Robin Bowlinger, RN, MS, director of quality at Sanford Medical Center, received a letter that was music to her ears.  Sanford received Top Performer on Key Quality Measures recognition by The Joint Commission based on 2012 quality scores related to heart attacks, heart failure, pneumonia, and surgical care.  This achievement reflects Sanford’s push for detailed clinical documentation and a close working partnership between case management, quality and its CDSs.

Sanford’s approach
To ensure quality core measures were interwoven with an increased focus on clinical documentation, Sanford added patient safety indicators (PSIs) and core measures into its CDI program software and used alerts for staff when both principal and secondary diagnoses raised any red flags.  The software identifies heart attack, heart failure, and surgical and pneumonia patients up front, and ensures that staff initiate and complete proven quality measures and processes for these diagnoses.

Collaboration is key
Whether it’s the CDS, quality department or case manager who gets to the chart first, the goal is to identify any flag quality core measure indicators and confirm with the physician that any noted complications or concerns are addressed.  For example, from January to October 2013, Sanford’s CDS team reviewed 2,448 cases for clinical and PSI measures, including both primary and secondary diagnoses, honing in on cases that needed to be addressed through intervention and physician clarification.

This focus on quality is actually not labor intensive with the aid of CDI software.  As the CDS, case manager or quality department opens the patient chart to review documentation, the core measures and patient safety indicators are automatically highlighted until they have been addressed.  If necessary, the CDS will create a physician and/or clinician clarification – or talk face-to-face – and within 24 hours the documentation is updated.

Core measure reporting, like many initiatives, is about creating documentation and correcting data to reflect patient care.  But, it’s more than words and codes.  This helps clinical teams deliver the right care every time, reduce morbidity, mortality, complications and readmissions, and ensure they offer the best, evidence-based care for their patients.  Improving quality metrics and patient safety requires a collaborative team effort. It is impossible to work in silos and improve patient outcomes as well as clinical data integrity and documentation.  Sanford’s CDI team exemplifies that collaborative approach by working closely with physicians and case managers.





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Mel Tully

About Mel Tully

As the vice president of clinical services and education, Mel oversees the development and expansion of clinical documentation programs and clinical education best practices. For the past 15 years, Mel has played an important role in the development and expansion of advanced CDI, and is recognized for her expertise and vision on the subject. She is a distinguished national speaker for compliance, clinical documentation, and the Hospital Quality Initiative, and has published newsletters and journal articles on a range of subjects, such as clinical documentation, health reform, value-based purchasing, reimbursement, patient safety, and compliance. Mel attended Emory University, where she earned her Master’s degree in Nursing. She has been certified through the Association of Clinical Documentation Specialists (ACDIS) as a clinical documentation specialist, as well as by the American Health Information and Management Association (AHIMA) as a documentation improvement practitioner. She lives in Atlanta, Georgia and is an avid supporter of the Atlanta Opera Guild. International travel is also a passion of Mel’s.