J. R. Gillen1, L. Jin2, J. M. Isbell3 1University Of Michigan,Surgery,Ann Arbor, MI, USA 2University Of Virginia,Surgery,Charlottesville, VA, USA 3Memorial Sloan-Kettering Cancer Center,Thoracic Surgery,New York, NY, USA
Introduction:
Hospitals are increasingly being judged by risk-adjusted quality metrics, which are directly influenced by the completeness and accuracy of medical documentation. This study evaluated the impact of a multi-faceted documentation improvement initiative. We hypothesized that this initiative would lead to improvement in risk-adjusted quality metrics.
Methods:
The prospective cohort consisted of all cardiac surgical patients over a 2-year period, divided into pre-intervention (2013) and post-intervention (2014) groups. The intervention took place in the cardiac surgery intensive care unit and consisted of 1) templated problem-based admission notes and daily progress notes, 2) distribution of pocket cards with diagnoses important to risk stratification, and 3) education of residents and faculty with documentation tips. Operative demographics and several indicators of patient acuity were compared between 2013 and 2014.
Results:
The pre- and post-intervention cohorts consisted of 768 and 791 patients, respectively. The distribution of procedure types performed were similar between groups (p=0.51). For the intervention group, there was a significant improvement in case-mix index (CMI) (6.86 vs 6.56, <0.001) and several University HealthSystem Consortium (UHC) quality indicators, including Severity of Illness (p<0.001) and Risk of Mortality scores (p=0.0014). However, there was no change in UHC expected mortality (3.69% vs 3.54%, p=0.49) or Society of Thoracic Surgeons (STS) Predicted Risk of Mortality (3.28% vs 3.11%, p=0.21). Additionally, documentation of complications increased in UHC data (11.76% vs 8,07%, p=0.018), but no similar increase was observed in STS data (11.81% vs 10.27%, p=0.25), suggesting a higher capture of complications rather than an actual increase in complication rates. The increase in CMI generated by this initiative correlated with an increase in hospital revenue of $3,849 per case, totaling over $3 million for 1 year.
Conclusion:
This documentation initiative was effective at improving CMI and UHC risk of mortality, which appears to have been primarily driven by improved documentation of complications. This study demonstrates that attention to accurate documentation can be an effective method to improve publicly reported quality indices as well as increase hospital revenues. Future interventions targeting clinic personnel documenting present-on-admission diagnoses may further improve these quality metrics.