North Mississippi Health Services (NMHS) is a rural healthcare system with locations throughout north Mississippi and northwest Alabama. The system’s flagship hospital, North Mississippi Medical Center (NMMC) in Tupelo, MS, is a 640-bed regional referral center and Level II trauma center that offers an array of medical specialties including medical, surgical, women’s, pediatrics, rehabilitation, hospice, behavioral health, and a neonatal intensive care unit (NICU).
NMMC is a 2006 recipient of the prestigious Malcolm Baldrige National Quality Award, and NMHS is a 2012 Baldrige Award recipient. The healthcare system also includes six community hospitals and a regional network of more than 45 primary and specialty clinics, nursing homes, and telehealth services. NMHS looks to continuously improve the health of the people of our region while providing the best patient- and family-centered care and health services in America.
As a clinical documentation integrity (CDI) manager, I look at response rate and response time from our provider queries. While we have a good response rate, I realized our response time could be improved. The time between the query being sent and being answered is valuable and, depending on the answer, could take the documentation in an entirely different direction or prompt additional queries.
The NMMC hospitalist program receives 75 percent of our queries, so we focused on this group. The program had a 95 percent response rate, but only 85 percent of those were responded to within the first 48 hours.
We decided to address this process with a Kata project. Kata is an approach to improving organizational activities to support a strategic purpose. It starts with a clearly defined challenge to strive for. For this, the challenge statement was: “It would be great if the query process was deemed valuable and collaborative by providers, thus assuring accuracy and timeliness of medical record documentation.”
Our next step was to determine the appropriate stakeholders. CDI serves many stakeholders in the project, including the hospital, insurance companies, quality, providers, coding professionals, the Centers for Medicaid and Medicare Services, and patients. We decided on a multidisciplinary team including members from CDI, information technology, coding professionals, health information management, and the medical staff.
Implementation and Action Plan
After forming our team, we started the Kata steps by asking “What is our goal?” We determined we would like to see 90 percent of queries answered within 48 hours. The biggest stakeholder is the provider, so we needed to involve providers and get their support. We solicited feedback from providers by asking these questions: What do you like about the query process? What do you dislike about it? How do you use the system? What is your workflow? How can we improve the process? This gave the providers a voice and gave us valuable feedback.
We learned of multiple issues and obstacles, including the following:
- No standard training for the query answer process
- No provider education related to repetitive queries
- Variability in provider coverage
- No process for providers to complete queries prior to rotating off
- No escalation process for queries that were answered disagreed with or more than 49 hours old
- No single method to assign queries
- No two-way communication process with the provider in case there was disagreement with the query
After identifying the issues, we met weekly to work the problem list and come up with potential solutions. As we worked through each issue one by one, we would implement a new process and test it. If it worked well, we kept it; if it did not work well, we “kyboshed” it and went back to the drawing board.
As a result of going through our processes, we found solutions to all identified issues. We met with the hospitalist service to ensure they had a clear understanding of CDI. We worked with IT to design a standardized education process for onboarding new providers and ongoing education. We provide monthly education to our providers via section meetings and we produce a “Tip of the Week” email. We adjusted the process, so providers get reminders to complete any open queries prior to rotating off shift and put in place an escalation process for any unanswered queries within 48 hours. We identified a method to keep CDI queries in the same location so they could easily be seen by providers.
We established a physician advisory panel that consists of four medical physicians and two general surgeons. This establishes a two-way communication between CDI and the providers and also helps to identify opportunities for CDI staff and/or provider education. Hospitalists are now supplied with a monthly scorecard to keep them engaged in the process, and they value the data they receive back from CDI.
Results and Next Steps
We found several new processes to improve our query response time during this project. As a result, we saw a steady increase in compliance and, by the end of the calendar year, our response rate within 48 hours was 95 percent. To date, our hospitalists’ turnaround time on queries averages 15 hours with a 98-99 percent response rate.
Providers want to document an accurate description of how sick their patients are, and they need education to do so effectively. Documentation is the only true thing the provider has 100 percent control over.
The medical staff found that clinical documentation is so important that they adopted a new rule into the medical staff bylaws: All CDI queries must be completed by the time the patient is discharged. This is a significant change. It reflects our efforts to involve providers and proves that they see accurate and timely documentation is seen as valuable.
We had several key takeaways:
- When you see an opportunity, research why that opportunity exists.
- Run trials with new processes. Keep those that work well and toss those that don’t.
- Involve providers. If you meet their needs, they will meet yours.
- Don’t “set it and forget it.” Make sure you are always reviewing data and researching trends and anomalies for continuous improvement.
- Implement a consistent feedback loop with your stakeholders.
Don’t be afraid to try to change processes. To ensure your new processes are accepted and stakeholders are pleased with the outcome, involve those who will be most affected by the change.
Kelli Hill is a system CDI manager at North Mississippi Health Services.
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