Mastering the art of anything, whether it is cooking, negotiating or clinical documentation, takes a commitment to pursuing ongoing improvements and an agreed upon mindset that settling for anything but the best is not optional.

Like other healthcare providers, we, at St. Luke’s, always strive to provide our community with first-rate care.  To us, the fast-approaching ICD-10 deadline doesn’t merely signal the implementation of a new coding system, it also holds the potential to drastically impact productivity and increase the potential for documentation errors which can lead to RAC audits.  With so much at stake, we knew that mastering the art of clinical documentation was critical to safeguarding the quality of patient care, addressing compliance regulations and ensuring appropriate reimbursement.

We are a six-campus organization, located in five counties across Pennsylvania and New Jersey.  A thorough assessment of our organization revealed that while our network physicians provide wonderful care, our documentation wasn’t at that same level of excellence.  We realized that a piecemeal approach to clinical documentation simply wasn’t going to cut it.  We needed an end-to-end solution that would offer a comprehensive, health system-wide approach to transforming our clinical documentation processes.  And while we recognized that our success hinged on achieving strong support from our doctors and senior administration, we also wanted to be conscientious of the fact that doctors need to be focused on patient care and not on maintaining records.  With this in mind, we developed a physician-first approach to teaching them what one of our physicians, Dr. Edward Gilkey, called “the art of clinical documentation.”

As with any art, success depends on leveraging the right tools, the right people and establishing the right vision.  After a year and a half of working with our clinicians, we are seeing dramatic changes throughout our health system.  Our case mix index (CMI) at all the hospitals has improved as much as 25 percent, and we are also seeing a marked improvement in our quality and severity of illness scores.

By focusing on the following approaches, we’ve been successful in transforming our clinical documentation program:

  • Engage physician advisors early and often:  At St. Luke’s, we have physician advisors at each of our six campuses.  We reached out to these clinical leaders and engaged them in our documentation process improvement planning, training and implementation.  We also recruited advisors from key clinical specialties — pulmonology and cardiology, critical care, vascular surgery, and orthopedics — whom we could reach out to when we had specific questions that required their unique experience and insight.  This collaborative approach created a real sense of partnership among the medical staff, practitioners, as well as the RNs, who serve as our clinical documentation specialists.
  • Offer peer-to-peer training:  Realizing that doctors learn best from other doctors, our documentation education brought together physicians by specialty.  We found that giving our clinical staff the chance to interact with their peers, who can provide relevant feedback and knowledge, is much more effective for doctors.
  • Rollout changes by specialty:  When training physicians on ICD-10 documentation, we found it tremendously helpful to focus on one specialty at a time.  This allowed us to cover the ICD-10 format of a specific diagnosis relevant to a specialty each month.  For example, with endocrinologists, we started with diabetes type II with hyperglycemia, giving doctors the opportunity to document a disease they know well.  Since then, we’ve moved on to other specialties and other diseases.  We’ve been doing this for about five months and the physicians have caught on fairly quickly.

The clinical impact of improved documentation compliance is apparent, but there’s been another, more profound impact.  This process has broadened the perspective of many of our physicians, inspiring them to think about how documentation quality affects both patient outcomes and financial performance.  They now recognize how documentation helps paint a more accurate, complete picture of what’s going on with the patient.  To me, the real “art of clinical documentation” is improved patient care.

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About Cheryl Davidson

This was a contributed post by Cheryl Davidson, RN, BSN, Clinical Documentation Manager, St. Luke's University Health Network. If you are interested in reading more about topics like this, please find much more in our healthcare section.