Communication Between HIM and Non-HIM Departments and the Effect on Quality Outcomes
The landscape of healthcare is most certainly changing, and the impact can be felt across many different areas of a hospital in different ways, from traditional hospital-based inpatient surgeries moving to ambulatory surgery centers, to independent hospitals being bought by larger health systems, to payers transitioning away from traditional fee-for-service payments to risk-based models. Corazon believes these changes are just the beginning, and the full impact has yet to be realized, especially in terms of payment models and how reimbursement is evolving for the hospital setting.
Transitioning to quality-of-care-based reimbursement from a flat payment for services rendered to the patient brings increased pressure to deliver appropriate care at the right time to the right patient AT THE LOWEST COST. Indeed, there has been a much greater emphasis on producing high-quality outcomes over the last several years, but now with the added intensity of an at-risk payment system that a hospital may or may not be prepared for.
In Corazon’s nationwide experience, a hospital may succeed at offering quality care, but these results may not always be reflected in the quality scores. For cardiovascular services, benchmarking through clinical outcomes registries, such as the American College of Cardiology’s National Cardiovascular Data Registry (NCDR) and the Society of Thoracic Surgeons (STS), can serve as indicators for quality of services provided. However, poor showings on these registries may not be accurate, and may be disputed by the medical staff of those programs.
Working with our client base around the country, trends of mediocre or poor quality scores is an issue regularly faced by many hospitals. In some cases, these results are truly indicative of less-than-stellar care being provided, which requires a root-cause analysis to determine action steps for improvement. It is vital that any and all poor outcomes are scrutinized to determine the reasons behind low-quality care.
However, in other cases where quality care delivery IS present, low scores are the result of other, perhaps more easily-remedied issues. Problems can originate from a lack of communication among key stakeholder departments in the hospital; specifically, the lack of an open and regular relationship between the Health Information Management Department (HIM) and the Quality Department. This breakdown or often, a complete lack of a relationship, can be fixed, but not without a time investment and willingness from both departments to understand the value of working together and the realistic obstacles to doing so.
Case Study: Addressing a Common Situation
In Corazon’s experience with a multi-specialty health system, quality metric scores were identified as a major issue facing the health system’s flagship hospitals. A multi-pronged approach was initiated (as outlined below) to identify what specifically was causing the low scores and subsequent work was completed to identify areas of opportunity for improvement.
1. Determine the Why. The first step is to understand WHY the quality scores are not meeting expectations. In our example, after Corazon met with hospital leadership, physicians, and representatives from the Quality Department, evidence proved that the quality scores did not reflect the quality of care provided by the clinical teams. Further investigation was required to determine why this discrepancy existed, starting with documentation activities.
2. Review the Documentation Process. The next step is to take a detailed look into the entire care documentation process, from coding a patient’s chart to extracting that data for the quality registry. Understanding the coding process and making sure that patients’ charts are being coded correctly is the most logical place to start. In this case study, this step revealed a larger issue that stemmed from an overall lack of communication.
3. Open New Lines of Communication. Establishing communication where it previously didn’t exist (or was minimal) between the HIM and non-HIM departments should occur. In this situation, the review of this process involved representatives from the cath lab, operating room, and quality management from both hospitals, some of whom had never met. This meeting initiated communication and solved one issue that needed to be addressed, which became a great starting point for improvement in the quality outcomes.
Reviewing with the appropriate personnel gave the group the opportunity to discuss the coding processes at each hospital, compare issues they face on a daily basis, and share site-specific strategies that have worked. Monthly recurring meetings were established so that both sides could update the other on progress being made. As a result of this exchange of ideas and sharing of methods, a standardization of protocols began to take shape for the health system…and quality scores improved.
4. Identify Opportunities for Improvement. After reviewing the process, comparing strategies, and sharing ideas, a checklist of steps that should be taken to make improvements should be created. For the hospital system in this case study, discussions among representatives from the Quality and Coding departments, along with the third-party abstracting department that the hospital contracted with for the quality registries, were necessary to improve scores. These discussions ensured that everyone could gain a deeper understanding of the process, while also giving the opportunity for the quality representatives to present some of the issues they were seeing.
During these discussions, one of the most important issues that surfaced was that of ST-elevation myocardial infarctions (STEMIs) that were either being coded OR abstracted incorrectly at times. In this instance, Corazon recommends that a team be formed with representatives from each of the three groups (coding, quality, and abstracting) to meet on a monthly basis to review each STEMI case to ensure accurate and consistent data entry and collection. As time goes on, and as the process becomes smoother, meetings do not need to occur as frequently. This is just one of the many relatively minor solutions that can assist with quality reporting and improvement processes.
According to Nelly Leon-Chisen, RHIA, of the American Hospital Association, “Non-HIM professionals, such as quality management staff, nurses, or physicians, may not be aware of coding requirements that have a negative impact on quality measurement results…By the same token, coding professionals may not be aware of the quality measures that the hospital reports.”1
This discrepancy held true for this case study. The meeting became tense at times, because as issues were presented, there were differing points of view about which department was responsible. Essentially, there was a figurative “wall” separating the coders and abstractors (Figure 1). The goal wasn’t to place blame on any one area, but rather to create a feeling of responsibility for everyone involved to enter, collect, and report accurate data. The discussion ultimately created a comfortable environment where staff from all three groups could talk out issues they were observing. In a short amount of time, this forum helped make their reporting more accurate and helped avoid previous mix-ups that were causing negative effects when reporting outcomes.
Consider This: Additional Strategies for Savvy Programs
- Invest in continuing education with the registries’ sponsoring organizations to maintain compliance with data definitions and changing interpretation of metrics.
- Participate in web conferences for regular updates and notification of pending changes.
- Develop an intra-hospital and inter-hospital network of professionals who are similarly engaged in abstraction.
- Review registry publications to become familiar with national trends and to periodically assess your organization’s performance against national norms.
- Share registry reports with abstractors, coders, and providers to encourage dialogue about the results and engagement in compliant documentation and reporting.
- Disseminate information through staff meetings, quality meetings, posters, and other tools within the organization.
- Include quality metrics in service line and departmental dashboards to ensure prioritization of quality outcomes with operational and financial benchmarks.
- Organize educational events based upon observed outcomes to elevate practice.
Potential Outcomes of This Effort
After facilitating the first few meetings, Corazon transitioned this task to the group members to address objectives, and continue the improvement and overall standardization of the coding and abstracting processes.
In just a few months after initiating these groups and opening new lines of communication, drastic improvements were achieved in both hospitals’ NCDR scores. The groups’ willingness to share information and understand the other sides’ issues cannot be underestimated. Without this cooperation between the members, such a sudden positive impact on the quality measures in the NCDR registry would not have been possible.
As the American Health Information Management Association notes, “Achieving high-quality, cost-efficient healthcare requires collaboration among all healthcare professionals and stakeholders. Currently the quality of healthcare tends to be inconsistent, disorganized, and inefficient.”2
The lack of communication in the example above is not uncommon. However, there are clear strategies that can assist with eliminating the common issues and moving forward with better communication in place to accurately report the quality delivered. Indeed, when communication between key departments is established, hospitals can expect to deliver care that is not only high quality, but that is also reflected in its quality measures.
- Leon-Chisen N. Coding and quality reporting: resolving the discrepancies, finding opportunities. Journal of AHIMA. 2007 July; 78(7): 26-30. Available online at http://library.ahima.org/doc?oid=71854#.W0wBBEm0WUm. Accessed July 19, 2018.
- Practice brief: HIM functions in healthcare quality and patient safety. Journal of AHIMA. 2011 Aug; 82(8): 42-45. Available online at http://library.ahima.org/doc?oid=104841. Accessed July 19, 2018.
Shane Recker is a Business Analyst at Corazon, Inc., offering strategic program development for the heart, vascular, neuro, and orthopedic specialties. Corazon provides a full continuum of consulting, software solution, recruitment, and interim management services for hospitals, health systems and practices of all sizes across the country and in Canada. To learn more, visit www.corazoninc.com or call (412) 364-8200. To reach the author, email firstname.lastname@example.org.