Healthcare News & Insights

Surprising link between documentation and safety scores

As ICD-10 draws closer, improving your doctors’ documentation should be a priority. But there’s another crucial reason why your clinicians need to keep detailed documentation: It could have a big effect on your hospital’s patient safety scores.

147349889In a blog post for the Wall Street Journal, Dr. Peter Pronovost, a critical care physician from Johns Hopkins and the director of the Armstrong Institute for Patient Safety and Quality, discusses the link between documentation and patient safety scores, specifically when it comes to measuring preventable harms.

Because of the heightened importance the feds are placing on safety scores, many hospitals are doing what they can to lower these numbers so they don’t get penalized. Dr. Pronovost argues that some of the initiatives, while helping patients, are actually lowering facilities’ scores.

Example: Blood clots in patients. According to Johns Hopkins research, hospitals that reported higher rates of patient blood clots actually had more aggressive screening procedures in place to find them. And although these hospitals are likely saving patients’ lives by finding these blood clots before discharging them, they’re penalized under federal law.

But ironically, other initiatives not directly intended to improve quality have unintentional positive effects on patient safety scores – including documentation improvement programs for physicians.

Why it matters

Clinicians’ documentation helps determine what’s billed to insurance companies. And while at first glance, this may not seem like it directly affects a hospital’s patient safety scores, it actually has a big impact on where a hospital ranks.

As Dr. Pronovost writes, the feds don’t usually get their information about a patient’s condition from the medical record; it comes from claims billed to Medicare. So any coding errors or inaccurate codes selected for a specific encounter can negatively affect a hospital’s safety rates.

For instance, a small blood clot may be accidentally coded as a deep vein thrombosis, which can artificially inflate patient safety rates because these cases are counted against a hospital.

The same goes for conditions that aren’t coded as existing before the patient was admitted. If that designation isn’t apparent for certain conditions, like pressure ulcers, they’ll be counted against the hospital that billed the encounter. And that’ll lower the facility’s safety score.

Effect on one hospital

Dr. Pronovost discusses a real-life example of how this happened at Johns Hopkins. After evaluating billing information against patients’ medical records, the hospital started an initiative to better train its physicians on documenting patient encounters properly.

The result: a 40% decrease in the hospital’s rates of preventable harm.

Here, documentation and coding improvement paid off. While the hospital did also implement some initiatives to improve patient care, it got a much larger boost from just improving how physicians document encounters.

What to do

If your hospital’s patient safety rates aren’t at the level you feel they should be, it may be worthwhile to review your facility’s billing, coding and documentation procedures along with looking at quality improvement initiatives.

Clinicians may well be providing exceptional care, but they may not always list the correct information in their documentation for billing and coding staff to accurately report encounters to payors. On the other end, billers and coders may not be aware that they’re accidentally using the wrong codes, so some refresher training could benefit them, too.

It’s always wise to look at ways to improve care quality and prevent patient harms, but your facility also deserves proper credit for the work it’s doing now. Making sure doctors are taking the time to thoroughly list all relevant details about hospital patients in their medical records can make sure your facility isn’t getting dinged unfairly for the care it provides.

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