COCOA: A multi-disciplinary collaboration to reduce HACs through appropriate documentation

2. COCOA: A multi-disciplinary collaboration to reduce HACs through appropriate documentation Nancy Rae Ignatowicz, RN, MBA, CCDS Provena Health, System Manager Clinical Documentation Nancy.Ignatowicz@Provena.org

3. Audience • Physicians • Infectious disease physicians • Nurses • Coders • Epidemiologists • Infection control practitioners • Other

4. I am glad you came to hear the stories behind the slides!

5. How many of you have had quality or infection control tell you that you coded the chart wrong? • How many of you have had quality or infection control dictate to you what you should be telling the physician in a query? • How many of you have had quality or infection control want you to question a physician’s documented diagnosis?

6. There are competing guidelines, rules, regulations, and definitions depending on which discipline you are from.

7. Agenda • Multi-disciplinary collaboration • Health information management: coding • Infection control practitioners • Infectious disease physicians • Impact of HACs (Immediate/long-term: financial, P4P, VBP, etc.) • Res Ipsa Loquitur • CAUTI~FMEA • CLABSI~PDSA • Process flow maps

8. Multi-disciplinary Collaboration CDI and reporting of patient safety data Ensuring documentation is present to reduce or eliminate the inappropriate reporting of a healthcare-acquired condition (HAC)

9. Communication and Collaboration Sharing data institutes and builds an environment for collaboration of internal partners and external customers. Fiscal management Information systems Infection control Infectious disease physicians Epidemiologist (PhD) Medical staff Risk management Material/supply management Nursing Quality management Patient Education CMO Health information management, clinical documentation, etc.

10. COCOAChartingObviousConditionsOnArrival Today’s focus will be on: CAUTI(catheter-associated urinary tract infections) CLABSI(central line–associated blood stream infections)

11. Public Report Cards:Where Do the DATA Come From? Reporting of CMS’ HACs are identified via ICD-9-CM codes and modifiers as those conditions which are reasonably preventable and able to be identified via coded information. The Infection Control HAI (healthcare-associated infection) surveillance report is manually submitted and can include data not reported via ICD-9-CM codes such as diagnostic results, which may contradict what the provider documented.

12. Coding BASED ON PROVIDER’S DOCUMENTED CLINICAL INTERPRETATION Cannot code from diagnostic results Must be documented by an approved provider Must meet the criteria to be coded as a PDx/ODx and POA • “Y” yes POA ~ will be paid • “N” not POA ~ will not be paid • “U” not determinable if POA ~ will not be paid unless death or AMA • “W” clinically not possible to determine POA ~ will be paid

13. CDC Infection Control Criterion:CAUTI • Looks at diagnostic results, not clinical S&S • Fever does not qualify as a symptom for UTI for IC reporting • If catheter discontinued >48H, may not be reported as CAUTI • Colony count may affect reporting • If >2 species, may not be reported • Not all organisms qualify as an IC CAUTI (e.g., candiduria)

14. Infectious Diseases Society of America: CAUTI • Classic S&S that denote a symptomatic UTI are not always useful for catheterized patients; having said that, S&S such as FEVER, rigors, AMS, malaise, lethargy, pain, etc., with no other identifiable source may indicate a CAUTI • Acknowledge gaps in our knowledge about CAUTI; burden for diagnosis is based on the CLINICAL JUDGEMENT of the treating physician • Recognizes funguria (candiduria) as one of the most common pathogens for a nosocomial UTI

15. CDC Infection Control Criterion:CLABSI • Use information from other sources besides provider documentation • Select units and defined time frames • Can use microbiology reports, pharmacy reports, communications from nursing staff, etc. • Must be an IC recognized pathogen(exclude common skin contaminants); looks for laboratory confirmation • Purulent phlebitis; +catheter tip; -BC; not a BSI per CDC

16. Infectious Diseases Society of America: CLABSI • CLABSI can originate from the catheter (i.e., tip, hub, lumen); a positive peripheral BC is needed for Dx, but a positive peripheral BC can be delayed by 2H compared to from the line • A CLABSI due to coagulase-negative staph frequently has FEVER alone but may also have catheter site redness. Coag-neg staph CLABSI may resolve with removal of the catheter alone and NO antibiotic treatment. • Antibiotics should be initiated based on CLINICAL CLUES

17. Financial Impact Immediate • AR/DNFC • Case-specific reimbursement • If another MCC/CC documented in medical record, financial anticipated reimbursement may not be affected

18. Why the renewed interest from quality directors?

19. Financial Impact Long term • Hospital Inpatient Quality Reporting Program required hospitals to begin submitting HAI data on Jan. 1, 2011; if a hospital does not participate, it will receive a 2% reduction in its annual CMS payment in 2012 • Marketing: HAC data will be found on CMS’ Hospital Compare website • P4P, VBP, third-party contractuals

20. Theory of Res Ipsa Loquitur The plaintiff will not need to prove the case, as the medical record will speak for itself by indicating the condition was not present on admission. Document to avoid civil torte OR How much should the check be written for?

21. Impact: Transparency/Marketing • Physician and hospital report cards • Clinical components may be defined by disease • LOS • Cost per case/CMI adjusted • SOI • ROM/RAM • Age • Complications • P4P, VBP, etc.

22. Pay for Quality, Not Quantity

23. CAUTI: FMEA Failure Modes and Effects Analysis: Even though we did not have an actual problem, we used this as an opportunity to be proactive in improving our processes by assessing for areas that could go wrong. Infection control, quality, nursing, education, medical staff, material/supply management,information systems, risk, etc.

24. CAUTI: COCOA Nursing POA Education

25. CLABSI: PDSA Plan-Do-Study-Act A negative trending was identified in our outpatient dialysis unit Apply lessons learned to inpatient area Patient,fiscal management, infection control, quality, nursing, education, medical staff, material/supply management, risk, etc.

26. CLABSI (CABSI): COCOA Nursing POA Education

27. Process Flow Maps Flow maps outlining our process for potential HAC investigation and the way we use it to keep our HACDNFC(discharge not final coded) down

28. Concurrent Process CONCURRENT: Documentation specialists look at select charts concurrently for clarity and specificity in codeable documentation. If a suspected HAC is identified, the team is alerted. CDN may query, if only POA clarification needed; otherwise, consultation with the team Collaboration and Communication

29. CONCURRENT POTENTIAL HAC Documentation nurse discovers potential HAC OR Infection control nurse, care manager, etc. notifies documentation nurses of potential HAC (phone/e-mail documentation) C OMMU N I C A T I ON Documentation nurse reviews chart for POA documentation per coding guidelines and notifies team as indicated; may query for POA POA determination made Review completed, as NOT a HAC C OOR D I N A T I ON YES POA NOT POA Documentation nurse notifies quality, risk, and infection control, as appropriate

30. Quality and/or infection control may discuss with physician regarding diagnosis of CAUTI or CLABSI! Regardless Whether POA Is in Question

31. Post-Discharge Process • POST-DISCHARGE: Each case (all-payer) is evaluated by a documentation specialist to determine whether it is an actual HAC or whether there are indications that the condition was POA. IC/quality also review chart, and IC/quality or CMO queries the physician if needed. • CDN may query, if only POA clarification needed; otherwise, consultation with the team • Collaboration and Communication

32. POST-DISCHARGE POTENTIAL HAC HIM: Health information management notifies documentation nurse of potential HAC B E F O R E F I N A L B I L L Documentation nurse reviews chart for POA documentation per coding guidelines and, if not POA, notifies quality/infection control; cases are reviewed regardless of immediate payment implications Not a HAC Review completed POA determination made YES POA NOT POA Collaborative decision is made: (goal 48 hours) AGREE or AGREE to Disagree HIM codes chart per coding guidelines Quality/infection control reviews chart; team discusses case; query written

33. Coding Collaboration We code only what is consistently documented in the medical record that meets coding guidelines for reporting PDx or ODx and POA Most of the time these are queries for SOI/ROM HIM coders and CDNs are integral parts of the POA/HAC team

34. Agree to Disagree • Coding needs a provider’s consistent DOCUMENTED clinical interpretation of the significance of a result/condition in order to code and apply modifiers per coding guidelines. • Infection control may use non-provider information and they look for laboratory confirmation, which may contradict what the treating physician documented.

35. Agree to Disagree We know we will not always agree, so we have agreed to disagree. We know ahead of time what our data will be, and we are able to explain any discrepancies between the different reports. All disciplines follow their rules and regulations for coding and reporting. GOAL: 48 hours so that AR/DNFC is not delayed

36. Patient Safety • Failing to connect the dots to realize an actual or potential problem exists (FMEA or PDSA) • Failing to report the findings to all the appropriate team members • Failing to do the follow-up and connect the dots with your stakeholders • Failing to analyze what your data mean … If you are not part of the solution, are you part of the conspiracy?

37. Ultimate Goals of HAC Communication and Collaboration

38. What We Have Discussed • Differences between what can be coded and what IC reports as a HAI • Multidisciplinary communication/collaboration • Immediate and long-term impact of a HAC (financial, P4P, VBP, etc.) • CAUTI ~ FMEA • CLABSI ~ PDSA • Res Ipsa Loquitur • Process flow maps

39. We at Provena Health are fortunate to have two clinical documentation nurses who formerly worked as infection control nurses. They were not able to be here today, but I want to acknowledge their extensive expertise and contributions to today’s session. Gina.Schultz@Provena.org Deborah.Phillips@Provena.org

40. 2011 HAC CMS Resources www.federalregister.govFederal Register, Vol. 75, No. 157; Monday, August 16, 2010; Rules and Regulation (on pages 50084–50085 is the list of the HAC ICD-9-CM codes) www.cms.gov/HospitalAcqCond/downloads/HACFactsheet.pdf www.cms.gov/MLNProducts/downloads/wPOAFactSheet.pdf

41. National Healthcare Safety Network “January 1, 2011, NHSN will be the tool used by facilities electing to participate in the CMS HAI IPPS Hospital Inpatient Quality Reporting Program, formerly known as Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU). As part of that program, central line–associated bloodstream infection (CLABSI) data from each facility’s adult and pediatric intensive care units and neonatal intensive care units will be reported to NHSN and shared with CMS. Each facility’s data will also be included in CMS’ Hospital Compare tool, which publicly reports hospital performance in a consistent and unified manner.” www.cdc.gov/nhsn/cms-welcome.html

42. Additional CAUTI Information www.cdc.gov/HAI/ca_uti/uti.html www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf www.cdc.gov/nhsn/forms/57.114_UTI_BLANK.pdf www.journals.uchicago.edu/doi/pdf/10.1086/650482

43. Additional CLABSI Information www.cdc.gov/HAI/bsi/bsi.html www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf www.cdc.gov/nhsn/forms/57.108_PrimaryBSI_BLANK.pdf www.journals.uchicago.edu/doi/pdf/10.1086/320001

44. Any Questions? Thank you