A tale of two worlds: Documentation versus clinical care

Dec. 21, 2018 / By Cheryl Manchenton, RN

Happy Holidays!  Sorry this is not a Charles Dicken’s Christmas story, but it does reflect an equally powerful story: A Tale of Two Cities. This Dickens novel has a well-known line: “It was the best of times, it was the worst of times.” One of the key themes of A Tale of Two Cities is the deep friendship and collaboration between two of the main characters. They are in many ways very different from each other, but the connection between the two main characters is ultimately what made for the best outcome (at least for one of them).

So, let’s apply that idea to mortality outcomes. Quality staff can’t control documentation and CDI/coding staff can’t control quality of care, but hospitals are challenged with improving their mortality profile and CMS star rating on mortality. Often, the two groups are working in silos or in adversarial relationships.  But should they be? 

Instead of pointing fingers, let’s think about what each department brings to the table for improving quality. The quality department can engage providers regarding the very public reporting of mortality as well as collaborate on changes in patient care that may improve outcomes. But there is also a need for an accurate record:

1. To ensure we are not reporting conditions that did not occur.
2. To ensure we are representing our total population’s clinical picture, including the overall severity of illness (SOI) and risk of mortality (ROM).

No single department has what is needed to completely explain or reflect the quality of care provided. Consider the following four-pronged approach:

1. Full capture by coding of all reportable conditions that meet UHDDS reporting requirements.
2. Consideration by HIM of holding cases with low SOI or ROM for pre-bill review to ensure no opportunities are available to capture or query for conditions that will impact SOI/ROM or profiling methodologies.
3. Increased querying by CDI beyond financials to show expected ROM. This will provide a little room when the observed death rate is encroaching on or exceeding expected mortality.
4. Engaged providers who will respond when asked to fully document or additionally document even when it doesn’t “make sense.”

And let’s also collaborate and share our current efforts to avoid the blame-game when mortality scores are not optimal.

It really isn’t the best nor the worst of times. When all of us do our part, we can improve the quality of care and obtain an accurate reflection of quality and mortality. 

Cheryl Manchenton is a senior inpatient consultant and project manager for 3M Health Information Systems.