Expert offers these guidelines
HIM professionals play an important role in collecting core measurements under requirements implemented by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.
However, to use core measurement reports most effectively, HIM staff will need to plan and prepare to improve processes for collecting, analyzing, and reporting the data.
Judy Finlan, RN, MBA, CPHQ, a product manager with QuadraMed Corp. in Neptune, NJ, offers these suggestions for establishing a sound and useful core measurement collection process:
• Select the most effective and appropriate vendor.
HIM departments need to make certain their vendors provide audit reports that are as clean as possible, Finlan says.
This means every data element must be completed, both in what is sent to the vendor and in what the vendor returns to the hospital, Finlan explains.
"One of the requirements that I’m not certain a lot of people fully understand is the fact that vendors have to report to the Joint Commission the number of records that are missing or have invalid data elements," Finlan says. "This makes it a lot more important than if there were just a missed discharge status every now and then."
Hospital systems should make certain their vendor has experience in handling patient-level data and has not simply analyzed aggregate data, Finlan suggests.
"It’s one thing to report that 15 of 45 patients have had a C-section, and it’s another thing to send data showing each patient who has had a C-section," Finlan says.
Also, hospitals should look for a vendor who is flexible and who listens to the client’s needs, producing the reports and formats the client wants, Finlan says.
The vendor should have a track record of reporting data to the Joint Commission and some experience in doing risk adjustment, Finlan adds.
"Most important of all, make sure the risk adjustment models are based on the use of UB data, so if you’re used to doing risk adjustment, you can look at the UB database and make sure things are reported in the right way," Finlan says.
Address data interpretation issues
• Make certain the vendor’s data and hospital’s data match.
Make certain the data being sent to the vendor are interpreted appropriately, Finlan advises.
In other words, be sure that what is sent in will be returned in the same context. This can be assessed very easily sometimes. For instance, if a core measurements report notes that 1% of patients died within the past month, but the vendor returns an analysis that says 25% of patients died, then obviously the vendor is not interpreting the data in the same way, Finlan says.
The problem could be that the vendor is switching fields in the database or considering some other baseline factor, such as admissions, rather than discharge status. The vendor may be interpreting the hospital’s format differently from the way that the HIM department expected, or reporting codes of patients that are not typical in the hospital’s experience, Finlan explains.
This type of data miscommunication needs to be resolved by HIM professionals and a hospital’s quality improvement staff through collaborative data reviews, Finlan suggests.
"I’ve always thought that the two departments had to work very closely together," Finlan says.
• Know what the Joint Commission wants and how to present it.
"You’ve got to be familiar with the questions and how the Joint Commission wants them answered," Finlan says. "Some of the clinical interpretations are slightly different from the way we’re used to seeing them in our everyday lives."
However, everyone has to use the same set of data definitions, or it would be impossible to benchmark and make comparisons, Finlan adds.
"The vendors don’t have any wiggle room," she says. "The Joint Commission has told vendors that these are the questions and these are the acceptable values, so it’s all in the clinical interpretation."
Most of the questions are straightforward, with the answers to most of them being "yes" or "no," dates, or times.
The job of HIM professionals and quality staff is to read between the lines while interpreting the findings.
Make sure comparisons are appropriate
• Learn how to make use of the reports and findings.
Each hospital should receive a description of its own outcomes on the core measurement areas, as well as benchmarks from similar hospitals.
Again, this is where the vendor selected is an important consideration, because it would be more useful for a hospital that specializes in open-heart surgery to be compared with other hospitals that provide that service than with small community hospitals that do not, and vice versa, Finlan notes.
"A community hospital might have a higher mortality rate for heart conditions because all of the people with a good likelihood of surviving are sent somewhere else for more treatment, so the community hospital ends up with those who are remaining," Finlan says.
To make certain one’s own data are being compared fairly, a hospital should ask the vendor for user-friendly reports that list how many hospitals in the database are similar to one’s own hospital in services, size, and other features, Finlan says.
"The Joint Commission will be providing all vendors with a national benchmark, and we had hoped they were going to break it out by bed size or teaching status, but I haven’t heard any definitive word that they’re doing that," Finlan says.
• Look for opportunities to improve.
The purpose of collecting and analyzing core measurements is to improve quality and develop a focus for performance improvement activities. This objective should be a top priority.
This is why it’s very important that HIM professionals assist quality staff in making certain that every item is coded correctly and includes all comorbid conditions, with risk adjustments identified and included in the codes, Finlan says.
For example, if an audit report for baby birth weights among neonatal mortalities includes a baby with a birth weight of 1,750 grams, but the ICD-9 code lists a range of 750-999 grams, then there’s a discrepancy on the audit report, Finlan says.
"Someone should check to see if the birth weight was listed incorrectly or whether the case was coded incorrectly," she adds. "You need to go back to the chart and see who made the mistake."
Go beyond routine audits
Errors typically may be small ones that are overlooked during routine chart audits. For instance, a clinician’s medical history may say that a particular patient smokes. Core measurement questions may ask directly whether the patient smokes, and if the answer is listed as "No," then there’s a discrepancy that would need to be listed as part of an audit report, Finlan says.
Discrepancies or omissions in comorbid conditions are another way that reports may be in error, and the Joint Commission wants comorbid conditions to be collected, so this area must be monitored, Finlan says.
"Say the patient has a principle diagnosis of myocardial infarction [MI] and is part of an acute myocardial infarction measure set," Finlan says. "But if the patient also has diabetes, that would be a comorbid condition, which increases the risk of having something bad happen to the patient while clinicians are treating the patient for the MI."
Comorbid conditions are collected through ICD-9 codes and will require answers to such questions as: "Did the patient get aspirin during the 24 hours before or after arrival at the hospital? Did the patient have contraindications to receiving the aspirin?" Finlan explains.
If these questions remain unanswered, then HIM staff will assist in finding the answers as it is their data that will be used to implement core measurements, Finlan says.
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