Getting credit for great work: Helping physicians improve documentation

For chief medical officers, a top focus is improving the quality and safety of patient care. When Dr. Gene Christian left his orthopedic practice for hospital administration, he expected to be leading clinical best practice and process improvement efforts. Then he discovered one of the most important aspects of quality improvement: how physician performance is measured.

If quality outcomes for length of stay, readmissions and other measures are higher than industry norms, is it a question of poor clinical care? Incorrect clinical pathways? Are physicians not following best practice? Seeking answers, Dr. Christian soon discovered that physician documentation didn’t accurately reflect patient complexity and the quality of care delivered. That’s when he became a disciple of clinical documentation improvement.

In many cases, our physicians actually were doing great work. They just weren’t getting credit for it, because they weren’t documenting properly…lt all comes down to what’s in the medical record and how it’s coded. Coding is everything.
— Eugene Christian, MD, Chief Medical Affairs Officer, Bon Secours Mercy Health System
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