Question

A clinical documentation improvement (CDI) specialist notices that one of the physicians from the cardiac catheter lab is now performing procedures in the operating room. Although this may be appropriate, the CDI specialist has worked in the facility a number of years and is not aware of any advanced training that would qualify this physician to perform procedures in the operating room.

1. What should the CDI specialist do?
2. What course of action should the facility take?
3. What course of action should the medical staff take?
4. What are the potential liabilities for the facility and the medical staff member?
   

Answer 1

1. What should the CDI specialist do?

Ans:-

Have you ever thought about all the paperwork that goes along with doctors and nurses treating your medical needs? From dentist cleanings to annual checkups, not to mention serious accidents or major surgeries, medical offices typically have stacks of paperwork for their patients.

Patients fill out some of these forms when they first go to a new doctor’s office, while medical professionals create others. These forms cover things like basic information and specific medical conditions that medical providers need to know.

It’s a lot to keep track of, which is why major hospitals and private practices alike often count on a clinical documentation specialist team to keep things running smoothly. If you’re considering joining the medical field, this could be a good opportunity for you.

Here’s everything you need to know about a day in the life of a clinical documentation specialist and how you can become one.

The Basic Duties

So, what does it mean to document specifics or review medical records? Put simply, a CDS has to make sure all the information gathered and recorded is accurate and detailed. They may go through every piece of paper and every line of medical code for each patient’s case.

When it seems like information is missing, or there is conflicting data, it’s often up to a CDS to fill in the blanks. These situations require the CDS to communicate with various departments to make sure a patient’s records are as accurate and in-depth as possible.

A Typical Day as a CDS

According to the American Nurses Association’s journal, an average day in the life of a CDS may look something like this:

• Evaluating a certain number of patient records
• Going through records for specificity and proper documentation
• Inputting document queries into a system for physicians, doctors, specialists, and other personnel
• Following up on previously unanswered queries or delayed answers
• Making sure the hospital or physician’s office gets proper Medicare reimbursement
• Contacting a patient’s insurance company if necessary

If you become a CDS, you can expect to be doing a lot of desk work and research. Your day-to-day will likely be spent inputting codes and double-checking values, with the occasional sorting and locating of certain paperwork.

Clinical Documentation Specialist Duties and Responsibilities

Based on job listings we analyzed, clinical documentation specialists’ duties typically involve:

Collecting Patient Information

Clinical documentation specialists collect information from medical teams about patients’ diagnoses and enter it into a computer database for security. They conduct research and perform administrative duties as well.

Assess Medical Documents for Accuracy

Clinical documentation specialists assess all medical documents for accuracy and ensure that records are systematically organized so that they can be easily located at a later date.

Check that Clinical Documents Comply with Laws

Clinical documentation specialists check that all medical documents comply with federal laws in terms of how they are composed and stored. They are responsible for assessing systems and recommending strategies for improving the record keeping process to provide better service to staff and patients alike.

Prepare Written Reports

Clinical documentation specialists work with staff to interpret reports to identify health-related patterns and assist in addressing health problems in patients, as well as preparing written reports for public health officials who evaluate the healthcare facilities.

Meet with Clinical Staff to Explain Reports

Clinical documentation specialists meet with clinical staff to explain reports. This involves applying their knowledge of medical terminology and procedures to evaluate clinical documents and address any issues in the reports.

The role of the Clinical Documentation Specialist Per the AHIMA Guidance for CDI programs, the role of the CDI professional is to help providers achieve complete and accurate documentation by:

• Facilitating and obtaining appropriate provider documentation within the medical record for clinical conditions and treatments required for accurate representation of severity of illness, expected risk of mortality and complexity of care of the patient.

• Exhibiting thorough knowledge of clinical documentation requirements as they relate to the classification systems, MS-DRG assignment, the clinical conditions and treatment needs of the patient population.

• Educating members of the patient care team and others regarding documentation guidelines.

• Facilitating the overall quality and completeness of the clinical documentation to accurately represent the severity, acuity, and risk of mortality profile of the patient being treated.

The CDI professional reviews the medical record on a concurrent basis to identify or obtain clarification for the appropriate principal diagnosis, secondary diagnoses and the principal procedure. The medical record is evaluated for completeness, consistency, precision, clarity, and legibility. Based on the clinical review a preliminary DRG is assigned by the CDI professional. The CDI professional provides education to physicians and other health care clinicians by providing formal and information education on documentation best practices and requirements and through the written and verbal clinical documentation clarification query process. The CDI professional aligns her/himself with the coding professionals by maintaining knowledge of the current Coding Guidelines, ongoing communication, and serving as a liaison between physicians and the coders. The skills required for this role include:

• A sound clinical background with a working knowledge of disease processes, anatomy and physiology and treatment regimens.

• The ability to analyze and interpret the clinical information in the patient’s medical record.

• A working knowledge of DRG formulation, Coding Guidelines and Coding Clinic guidance.

• Strong written and verbal communication skills demonstrated by the ability to effectively communicate with physicians and other clinicians.

• Knowledge of healthcare regulations, reimbursement and documentation requirements.

The Clinical Documentation Improvement Specialist (CDIS) is responsible for competency in coordinating and performing day to day operations, providing concurrent and/or retrospective review, and improving documentation of all conditions, treatments, and care plans to ensure highest quality of care is provided to the patient. The CDIS will also education clinical staff in appropriate documentation criteria. QUALIFICATIONS An Associate’s degree in a healthcare related field with a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician), CCS (Certified Coding Specialist) credential or RN (Registered Nurse) or MD (Medical Doctor) license is required. COMPETENCIES

• Identify principal and secondary diagnoses in order to accurately reflect the patient’s hospital course utilizing ICD-10-CM with appropriate application of coding conventions and guidelines

• Ensure accuracy of MS-DRG groupings and APC assignments

• Promote CDI efforts throughout the organization and collaborate with physician champions to promote initiatives

• Foster working relationship with CDI team members

• Query providers in an ethical manner and track compliance

• Develop CDI policies and procedures to include query process, education and training, and performance tracking RELATED TECHNICAL INSTRUCTION

• Skills assessments based on certification domains

• ICD-10 training based on employer needs

• AHIMA online CDI courses

• Use of CDI textbook and online exercises

• Common employability skills such as communication; analysis and problem-solving; teamwork, business knowledge and behavioral characteristics.

2. What course of action should the facility take?

Ans:-

The Clinical Documentation Improvement Specialist (CDIS) is responsible for competency in coordinating and performing day to day operations, providing concurrent and/or retrospective review, and improving documentation of all conditions, treatments, and care plans to ensure highest quality of care is provided to the patient. The CDIS will also education clinical staff in appropriate documentation criteria. QUALIFICATIONS An Associate’s degree in a healthcare related field with a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician), CCS (Certified Coding Specialist) credential or RN (Registered Nurse) or MD (Medical Doctor) license is required. COMPETENCIES

• Identify principal and secondary diagnoses in order to accurately reflect the patient’s hospital course utilizing ICD-10-CM with appropriate application of coding conventions and guidelines • Ensure accuracy of MS-DRG groupings and APC assignments

• Promote CDI efforts throughout the organization and collaborate with physician champions to promote initiatives

• Foster working relationship with CDI team members

• Query providers in an ethical manner and track compliance

• Develop CDI policies and procedures to include query process, education and training, and performance tracking

• Skills assessments based on certification domains • ICD-10 training based on employer needs • AHIMA online CDI courses

• Use of CDI textbook and online exercises

• Common employability skills such as communication; analysis and problem-solving; teamwork, business knowledge and behavioral characteristics

The course has been designed by professionals with experience in the real healthcare settings. As the demand for accurate and timely clinical documentation increases, health information management (HIM) professionals are using their skills and expertise to improve documentation. This course directed toward clinical documentation specialists or related roles in healthcare settings. The course structure appropriately covers all essential of documentation improvement in medical coding along with live examples, CDI alert and clinical tips. Since this is a useful program for coding professionals; however, the courses focus on documentation assessment and improvement as they support code assignment (the program does not contain any training on how to code for reporting or indexing). The course offers to be a re-fresher course for existing employees who already know about the industry and ICD-10-CM but are interested in training or updating onto the clinical documentation improvement.

IGMPI has long been a part of the healthcare education chain and has been into the field with its many professional’s healthcare courses. This yet another one has been an addition to the basket of existing ones. This is a fast track and advanced course having CDI alert and clinical tips based methodology throughout the duration.

Goals

• To identify and clarify any confusing, incomplete, conflicting, or missing information in the physician-documented portion of the health record that is related to diagnoses or procedure;
• To enhance communication between members of the CDI team and the medical staff;
• To provide education to medical staff members.
• To improve continuity of care for the patient, between members of the healthcare team.
• To provide accurate representation of patient severity;
• To provide education to coding staff members to increase their clinical knowledge.

Since clinical documentation is vital to the success of any healthcare organization, now is the time to step up clinical documentation improvement (CDI) programs. Whether kick-starting a CDI program or reinvigorating one, you will want to build a strong foundation for sustainable success.

Formalize Efforts with a Steering Committee

The first step should be to establish a CDI steering committee that includes key interdisciplinary leadership impacted by CDI. While every organization is unique, most committees should include the following representatives:

• Chief financial officer
• Chief medical officer
• Physician champion
• Director of the clinical documentation improvement program
• Director of health information management
• Director of coding compliance
• Director of continuum of care
• Director of quality
• Vice president of nursing

The first project for the committee should be to clearly define the objectives and expected outcomes of the CDI program. Identify and monitor key metrics and develop dashboards for reporting. At a minimum, the dashboard should include the following:

• Documentation review rate
• Query rate
• Response rate
• Impact
• Case mix index (CMI) trend

Measure Progress to Sustain Momentum

The CDI program head must measure progress, recognize the challenges, and take corrective action as needed. As the CDI program matures, the data captured can be increased to expand the dashboard presented to the CDI steering committee. Other areas to monitor include the query response rate by physician, types of queries generated, and trend CC and MCC capture rate. The metrics can be used to pinpoint opportunities for education.

A physician advisor is paramount to a successful CDI program. The physician advisor serves as a CDI advocate, resource, educator, and a liaison for documentation specialists, coders, and providers. The physician may also participate in reviewing denials and assisting with appeals. Participation as a member of the CDI steering committee should be included in the roles and responsibilities of the physician advisor since they should be well versed in all aspects of the clinical documentation improvement program. It is also important to cultivate unofficial physician supporters; front-line physician support can speak in support of CDI efforts while interacting with the medical staff.

The clinical documentation specialist (CDS) has many roles, but none more important than a complete and thorough concurrent record review. Many CDI programs are implemented for the sole purpose of capturing documentation for reimbursement. While accurate reimbursement is a benefit, the CDS must also understand the far-reaching impact of the clinical documentation on care accuracy and quality. This is typically the biggest selling point—improved patient care—that a CDS has when trying to convince busy physicians to provide better documentation.

CDI programs should start simple. One of the basics that clinical documentation improvement practitioners should know and understand is the “present on admission (POA)” definitions. POA has the potential to impact reimbursement as well as quality reporting. POA categories include:

• Y – condition was present on admission
• N – condition was NOT present on admission
• W – provider is unable to clinically determine whether condition was present on admission or not (Note: “W” will be treated the same as “Y” by the Centers for Medicare and Medicaid Services (CMS))
• U – documentation is insufficient to determine if condition is present on admission (Note: “U” will be treated the same as “N” by CMS)
• E – diagnosis is exempt from POA reporting

POA is federally defined as “present at the time the order for inpatient admission occurs.” Conditions that develop during an outpatient encounter, including emergency department, observation stays, and same day surgery are considered to be present on admission. Timing of the documentation does not matter. The physician may document that a diagnosis was present on admission at any time, such as in the discharge summary or in a post-discharge query. If the documentation is unclear, then the CDS must query the physician for clarification.

CMS has a number of quality programs that require complete and accurate documentation as an important reporting component. Claims-based measures originate from clinical documentation and have a vital role in quality initiatives. These programs include:

• Inpatient Quality Reporting (IQR)
• Value-Based Purchasing (VBP)
• Hospital Readmission Reduction Program (HRRP)
• Hospital-Acquired Conditions (HAC)

Work closely with the organization’s quality department to better understand the role clinical documentation specialists play in helping meet these quality initiatives.

Take advantage of the findings from the Program for Evaluating Payment Patterns Electronic Report (PEPPER). The report is published quarterly and includes statistical claims data for MS-DRGs at risk for improper payment due to issues with billing, coding, and/or medical necessity. The report compares data at the national and state level, and identifies a hospital’s outlier status of high, low, or in the expected range. The findings from PEPPER can be used to develop auditing, monitoring, and action plans at your hospital or facility as needed.

The Office of Inspector General (OIG) is responsible for protecting the integrity of US Department of Health and Human Services (HHS) programs by detecting and preventing fraud, waste, and abuse. The OIG Work Plan is published annually with an overview of the reviews and activities the OIG plans to pursue. Review the OIG Work Plan to understand the hospital-related policies and procedures and the areas targeted for review. Then, implement an internal data mining process to identify areas of vulnerability included in the OIG plan and develop a corrective action plan.

The importance of collaboration cannot be overstated. The CDS has valuable insight into the clinical documentation beneficial to the revenue cycle team. CDI staff should consider participating on the denials team to understand what is being denied due to documentation and how to proactively assist with documentation up-front. Is the revenue cycle team holding claims due to unanswered queries? Having a good rapport with the medical staff helps facilitate a prompt response to queries. There are many quality initiatives that depend on clinical documentation and the CDS needs to stay informed in order to understand the impact documentation has on quality initiatives.

Partner with coders to build and strengthen the CDI program. Monthly team meetings to review rules and regulations that govern coding, query development and compliance, and record reviews foster team building and provide opportunities to share knowledge and skills. Evaluate which queries are being generated retrospectively and review to determine if the queries can be generated concurrently.

Contribute to the development of query templates and review queries generated to promote compliance. Also, CDS and coding team members can collaborate on data mining projects to identify accounts that may be included in the PEPPER or OIG Work Plan focus. Assess the documentation and the final coding to confirm complete and accurate information. If a trend is identified, it may be beneficial to proactively review vulnerable accounts before the final coding is submitted.

A second-level review by a coder and a clinical documentation specialist can decrease denials. Accounts with HACs should also be referred to the quality department for review prior to the final coding in order to determine if the condition was present on admission or hospital-acquired. In addition, the review should include clinical evidence to support the validity of the diagnosis. A solid CDI program is one that moves out of a silo and develops a team-based approach, promoting efficiency and accuracy.

The CDS must take the responsibility to review every record from a holistic perspective, including for POA and clinical validation. When the patient goes home the record must stand on its own. CDS professionals should ask themselves, “Does this record clearly and accurately reflect the condition of the patient and services rendered?” If the answer is yes, then congratulations on a job well done.

This programme provides information on the terminology utilized in ICD-10-CM that impacts clinical documentation.This identify areas in ICD-10-CM that include new terminology, define areas in ICD-10-CM that enable improved data capture and discuss methods to employ to educate physicians of new documentation opportunities.

The intention of this course is to introduce health information management (HIM) professionals to the exciting new world of Clinical Documentation Specialists. Within this course, professionals will learn about important skills and areas of knowledge that will assist them in becoming successful Clinical Documentation Specialists. Participants will come across the following topics:

• Understand the Clinical Documentation Specialist (CDS) role and skill requirements
• Discuss necessary coding skills and knowledge about the MS-DRG system needed to be a successful CDS
• Explore the topic of optimal communication methods with physicians
• Discuss specificity and the reason for the necessity of concrete documentation in the medical record
• Examine how minimal documentation can affect potential reimbursement
• Identify best queries and value the physician as part of the query process

The case study based approach in CDI Training programme via Regular, Part-time and interactive modes is designed for professionals who wish to complete the course in shorter time duration. This course is beneficial for professionals from different streams to help them intensify their knowledge. This is a fast track and advanced course having rigorous case studies based methodology throughout the duration.

3. What course of action should the medical staff take?

Ans:-

The following is likely not a surprise to those clinical documentation improvement specialists (CDS) working day in and day out improving physician documentation. But for the record-clinical documentation improvement (CDI) is not taught in medical school. The truth is that most physicians have no idea what CDI means and why it should be important to them. But it is important.

CDI programs have increased significantly over the past 10 years due to changes in reimbursement and increased scrutiny by third party payers. As a result, hospitals have invested a significant amount of time and resources to hire CDSs to review charts and identify conditions that were evaluated, monitored, or treated during the hospital stay but were not documented in a way that can be coded. Physician participation and buy-in can be difficult since some physicians feel that CDI programs exist only to benefit the hospital and just add more work. But some insider tips-provided by a physician-can be used to promote CDI programs to members of the medical staff and engage their willing participation in the process.

Steps of Action Planning

1. Define the Problem(s)
2. Collect and Analyze the Data
3. Clarify and Prioritize the Problem(s)
4. Write a Goal Statement for Each Solution
5. Implement Solutions: The Action Plan
6. Monitor and Evaluate
7. Restart with a New Problem, or Refine the Old Problem

Step 1: Define the Problem(s)

Evaluate the situation. Have all possibilities been considered? In this stage, explore all possibilities, ask all involved or interested individuals for their input into identifying the problem. Is there just one problem or are there more?

Our farm owner conducts a thorough investigation in trying to determine why the bulk tank weights are down. He checks with the veterinarian to be sure there is not a contributing health factor. He also has the nutritionist evaluate the ration to be sure they are feeding at the proper level. In addition, he interviews employees who interact with the cows on a daily basis. This is what he finds:

• Standard Operating Procedures are being followed thoroughly in the milking parlor.
• Several substitute feeders found some premixes in short supply. In order to feed the milking cows they had to prepare premixes before mixing the herd rations.
• The veterinarian visits and reports the cows are in good health.
• The nutritionist evaluates the rations and finds them to be appropriate for the various production groups.

The farm owner begins to suspect the problem is a result of variation in the feed ration being fed as a result of different people mixing the feed.

Step 2: Collect and Analyze the Data

Now that we have identified the problem, we collect and analyze data to prove or disprove the assumption that our problem is a result of inconsistent ration. We analyze the situations by asking questions.

• What ingredient(s) in the computer ration is the likely problem?
• What do others (veterinarian, nutritionist, herdsman) see as the reason for the lower bulk tank weights?
• What do the feeders see? How much feed is in the alley when new feed is put out?
• What does test data indicate? Compare the sample analyses of the ration being fed, the ration being eaten by the cows, and the ration left when new feed is delivered.

In our scenario, the farm owner reviews the bulk tank weights and confirms that tank weights are down. Next he checks the cow numbers to see if perhaps these are down. Instead, he finds that cow numbers are up. As he is gathering data from the employees he is reminded that the old feeder left for a new position. He finds that different people have been pitching in to mix the feed ration. The owner begins to suspect that the cow's daily rations are not being made consistently. He reviews analysis of feed samples at the next three feedings and finds that the variation is beyond the limits for acceptability.

Step 3: Clarify and Prioritize the Problem(s)

If there is more than one problem, you will need to prioritize the problems so you can focus on the most important problems first. Ask the following questions to help you sort the problems with the higher priority issues at the top of the list.

• Which problem could result in negative consequences in terms of cow or employee health?
• Are any of the problems putting the operation in danger of being in noncompliance with regulations?
• Which problems have the greatest impact on the long-term economic stability of the operation?
• Which problems have short-term impact on the stability of the operation?

In this case we only have one problem -- lack of a consistent ration so prioritization is not necessary.

Step 4: Write a Goal Statement for Each Solution

The next step in the process is setting S.M.A.R.T. goals, or goals that are:

• S - Specific
• M - Measurable
• A - Achievable
• R - Relevant
• T - Timely

The team needs to go through the problems that have been identified and evaluate them for each of these items. If all the goals that have been set are S.M.A.R.T. goals, great -- you are ready to move on to Monitoring Progress. Otherwise, work with the team to make the necessary adjustments to make the goals S.M.A.R.T.

S - SPECIFIC

Specific goals are clear and focused, not broad, ambiguous, or general. Specific goals provide specific information on the behaviors that are associated with the goal. These goals indicate who will do what, when and how.

• Example of a goal that is not specific - "The advisory team will improve Pleasantview Dairy's profitability."
• Example of a specific goal - "Employees of Pleasantview Dairy will lower feed costs by producing high-quality forages (RFV>125), having forage equipment in top working order by May 1, storing the first crop of hay silage by May 25, and continuing to harvest at 31-day intervals throughout the growing season."

M - MEASURABLE

Measurable goals provide a measurable indicator of success, so that it becomes easy to monitor progress and determine when success has been attained. Measurements of success may be quantified with numbers or a simple yes/no determination.

• Example of a goal that is not measurable - "Employees of Pleasantview Dairy will improve feed quality."
• Example of a measurable goal - "Employees of Pleasantview Dairy will increase the average relative feed value from 100 to greater than 140 for all hay silage stored this summer" or "All ingredients in the TMR will be weighed using the electronic scales and delivered to the feed bunk by 10:00 a.m."

A - ACHIEVABLE

Achievable goals are realistic, and well within the abilities, responsibilities and resources of the management and staff. This does not mean that goals must be easy to achieve. Every effort should be made to reach a higher level of performance. Sometimes "stretch" goals can encourage someone to step out of their comfort zone and tackle tasks in a new, challenging, yet achievable way that results in overall improvement for the operation.

• Example of a goal that is not achievable - "Milk yields will exceed x amount," where x is beyond the limitations for the breed of cattle, facilities and management of the operation.
• Example of an achievable goal - "Farm employee x will mix feed ingredients accurately (wet feed less than 5 percent and dry feed less than 1 percent error) and deliver it to the cows by 10:00 a.m."

R - RELEVANT

A relevant goal is appropriate to a person who will be attempting to achieve it and to the overall goals and objectives of the farm.

• Example of a goal that is not relevant - "All feed will be delivered to the cows by 10:00 a.m." This goal is easy enough to measure and achieve, but doesn't do anything to ensure the quality of the feed.
• Example of a relevant goal - "Farm staff will improve milk production and lower feed waste by assuring that the computed ration is fed to the cows accurately, in the proper amounts and by 10:00 a.m. each morning."

T - TIMELY

The attainment of a goal should not be open-ended, but set for a specific time. As much as possible, the exact date the goal is to be achieved should be determined. When a goal has a deadline, it provides a measurable point and speeds progress toward critical goals. Employees will generally put more emphasis on goals that have specific deadlines than on those for which no time for measurement has been established.

• Example of a goal that is not timely - "We will increase milk sold per worker to 1.2 million pounds."
• Example of a timely goal - "We will increase milk sold per worker to 1.2 million pounds by July 1 of next year."

Now, back to our example - an appropriate S.M.A.R.T. goal for this situation would be to write a standard operating procedure (SOP) by tomorrow evening's feeding so that everyone that is assigned to feed the cows unexpectedly can easily follow the steps and assure that the cows are fed correctly twice daily, at 6 a.m. and 6 p.m.

Step 5: Implement Solutions - The Action Plan

Step five is to write an action plan that addresses the problems. An action plan is written so that any employee can do the task successfully alone and is followed much like a recipe. It converts the goal or plan into a people process. It has three essential parts:

1. Based on the goal the action plans answers five questions - What? When? How? Where? Who?
2. Lists Resources
3. Lists Potential Barriers

The example below applies these steps to our sample problem. Some of the steps in the action plan are obvious.

• What? - Feed the cows correctly twice a day.
• When? - By tomorrow night.
• How? - The written SOP.

SOME QUESTIONS STILL NEED ANSWERS IN THE ACTION PLAN:

• Where? - Feed is to be mixed in the feed wagon using the green tractor on the concrete pad by the commodity bins next to the silos. The feed is then to be fed to the cows in lots 2, 3, and 4 twice daily, at 6AM and 6 PM.
• Who? - To be assigned by the herdsman until a new feeder is hired and trained.

RESOURCE LIST:

• Ask the herdsman for help if any questions arise.
• The feeds are in the feed storage area and will be replaced as they are used.
• The tractor and mixing wagon are in the shed by the feed storage.
• The feeder is authorized to order feed or ask the office to do so.
• The feeder can spend up to $300 to correct problems when the office is closed and should get parts on account at Dickerson's Equipment.

POTENTIAL BARRIERS:

• Depleted feeds in silos or bins.
• Tractor is in use somewhere else.
• Broken equipment.
• Sick employees.
• Cows in the wrong lot.
• Scales broken.

You will want to post an alternative plan for each of these contingencies.

Step 6: Monitor and Evaluate

Our next step in the problem solving process is to design a method for monitoring the outcome. The method we select should assess whether the goal and action plan corrects the problem. In addition, a well-designed monitoring method will help the team to determine when the action plan needs to be improved.

A team of professionals should not spend much time going over numerous data sets. They should have simple spreadsheets or graphs that tell how well the action plan is working and move on to bigger problems. Most teams need a short list of key parameters related to goals that they follow each meeting. An extensive list of production items is provided in the Resource/Special Tools section for ideas. Many teams track summary data from accounting reports, inventories of resources, or other items critical to monitoring action plans.

At each team meeting, the team should receive an update on the progress towards meeting the goals including any difficulties encountered or benefits received. Printed reports, summaries and spreadsheets speed the work of the team and help track progress. As time passes and situations change, the team will need to reevaluate individual goals and action steps as well as eliminate any that are no longer necessary. Add new goals as the need arises.

In our example, there were several components of the monitoring and evaluation process.

• Grab samples were taken and analyzed at each feeding for the next two weeks.
• The herdsman routinely observed the feed mixing process to see that the standard operating procedure was being followed.
• Bulk tank weights were monitored and plotted with cow numbers on a graph on a wall in the parlor office.

Monitoring Tools: Sample Herd Report

Step 7: Restart With a New Problem, or Refine the Old Problem

The problem solving steps are cyclical. If the first cycle is successful the process starts over with a new problem. If the same problem persists, there must be refinement, so the process starts over with refinement of the original problem as more current data is analyzed.

The problem solving process can last minutes or extend to years depending on the difficulty and complexity of the problem being addressed. Some problems will be addressed "on the fly" by the farm owner. Others will require careful consideration by the farm advisory team.

Make CDI about Quality

The main message to physicians should be that CDI is a quality initiative. When asking physicians why good clinical documentation is necessary, they will most likely say that it is to document the care of the patient and to communicate with other providers. Physicians understand the need to make documentation legible, timely, complete, precise, and clear. They understand that the documentation is the legal health record. They understand the common phrase “If you didn’t write it, it did not happen.”

Physicians are not taught how to complete the documentation in order to accurately assign codes, and physician billing does not require a high degree of specificity. A diagnosis of congestive heart failure, not otherwise specified (CHF NOS), is perfectly acceptable for physician billing. However, the lack of specificity on a hospital record can affect payment. The key is to engage physicians to correlate how clinical documentation provides an opportunity to demonstrate the quality of care that was provided.

The message to physicians should be simple-good clinical documentation will improve communication, increase recognition of comorbid conditions that are responsive to treatment, validate the care that was provided, and show compliance with quality and safety guidelines. Although the message is simple, there are some challenges when trying to present this information to physicians. Physicians are by nature independent thinkers and will expect a very concise, clear reason to change documentation habits.

Recommendations for how to address CDI with physicians include:

• Know your audience-academic physicians, private practitioners, mid-level providers, and students should each be approached differently
• Incorporate CDI training with ICD-10-CM/PCS-this reduces the number of messages for clinicians
• Tell them why CDI is important
• Make CDI part of the clinician workflow
• Documentation queries need to be consistent with clinical practice
• Queries must be consistent with evidence-based guidelines
• Provide meaningful data and feedback to facility clinicians

Teamwork in health is defined as two or more people who interact interdependently with a common purpose, working toward measurable goals that benefit from leadership that maintains stability while encouraging honest discussion and problem solving. Researchers have found that integrating services among many health providers is a key component to better treat undeserved populations and communities with limited access to health care.

Build a patient safety culture

Any effort to establish a patient safety culture in an organization is ideally led by the following proven practices:

• Simplify and standardize workplace, equipment, supplies and processes.
• Establish constraints that encourage and drive medical professionals to do the right thing.(e.g. provide an electronic medical record chart that provides visual cues to accurately chart a patient's information).
• Reduce reliance on memory and other weak aspects of cognition.
• Foster robust communication between stakeholders to encourage a comprehensive understanding of the problems associated with patient safety. Communication failures often contribute to preventable patient harm events.
• Conduct training for medical professionals so that they are well-equipped to perform their responsibilities.
• Plan interdisciplinary team training programs and collaboration on areas such as patient care simulation.
• Ensure that managers and leaders in the organization continually contribute to the process of improving quality.
• Build an organizational culture that strikes a balance between fairness and accountability and is conducive to ongoing quality improvement.
• Collate patient safety data, monitor and evaluate errors, and implement methods to reduce them.

4. What are the potential liabilities for the facility and the medical staff member?

Ans:-

The liability of the hospital for the actions of a medical staff member flows from the duty to ensure the competence of the medical staff. Except in employment or agency situations, the hospital is not directly liable for the negligent actions of a medical staff member. For example, if a nurse gives a patient the wrong medicine, the hospital would be liable for the mistake. However, if a physician gives a patient the wrong medicine, the hospital would not be liable unless it was negligent in allowing the physician to have (or continue to have) staff privileges.

The granting of staff privileges could be ruled negligent for one of three reasons:

(1) The criteria that were used to evaluate the applicant were insufficient to determine the applicant's competence.

(2) The hospital board knew that the physician was incompetent.

(3) The board should have known that the physician was incompetent. The third situation, "should have known," is narrowly defined. It usually refers to circumstances where the nursing or the medical staffs were aware that the physician was having trouble. The board members can be put on notice of misbehavior by the reports of staff members or on the basis of their personal knowledge or information from an outside source, such as patient complaints. A failure to act when the board members have personal knowledge of negligent behavior could, as noted earlier, result in personal as well as corporate liability.

The breach of the initial duty to screen applicants for basic medical abilities is seldom sufficient to support a malpractice judgment. The failure must be obvious to reach the level of negligence. The board is allowed nonphysicians to be called doctor and to write medication orders on patients. A more common problem involves a failure to check the references be checked. A hospital that fails to discover that an applicant lost privileges elsewhere could be liable to patients injured by that physician.

Failing to discipline a physician for acts of negligence or bad judgment is the best-established basis for a suit based on negligent entrustment. If the hospital is to avoid liability, the board must act when it knows of wrongdoing. The chance of a board member being held personally liable is remote at this time, but rapid changes are being made in this area of the law. Lawsuits based on negligent entrustment are a very serious problem. One bad physician can injure many patients, all of whom are potential plaintiffs. If the suits go to trial, the jury may be enraged by the hospital's failure to discipline the physician, despite knowing about the physician's outrageous conduct. From the public relations point of view, this type of incident can affect the reputation of the entire medical staff.

The issue of when the board "should have known" about the physician's misconduct is most difficult to resolve. The courts must balance liability for actions that the board did not know about against allowing the hospital to escape liability by ignoring its duty to oversee the medical staff. The board must avoid the temptation not to find out what is happening in the hospital. In a self-insured facility, the potential losses from lawsuits by a group of injured patients could be devastating. The amount in a self-insurance trust is based on past experience of the facility and other like it. The calculations assume a relatively steady, fairly random, occurrence of claims. A grossly negligent physician could generate a unpredictable string of claims that could greatly exceed the amount in the trust. (Even conventional insurance has limits on the total claims paid during a given period.) Successful long-term planning must include ways to monitor the performance of the medical and nursing staff. But detecting wrongdoing is only the first step. The hospital must also be prepared to intervene to remedy the problem. Intervention is politically difficult, but a failure to intervene will open the way for malpractice litigation.

The most difficult situation to deal with is that involving a physician who is rendering dangerous care. The critical issue is to provide substitute care for the physician's patients. This is a problem separate from that of disciplining a negligent physician. The hospital bylaws must provide a procedure for the temporary suspension of privileges and the provision of transitional care. This is a drastic remedy, but without it the hospital may not be able to protect patients adequately from negligent injuries.

There must also be a provision for the emergency review of privileges. All suspensions should be reviewed by a physician committee, but there must also be a provision for emergency suspension by the hospital administrator. An obvious case would be a physician who comes to the hospital intoxicated. Intoxication sufficient to impair the physician's judgment would be obvious to the nursing personnel. The administrator must be able to suspend this physician's privileges temporarily. Once the nursing staff is aware that a physician is impaired, either by illness or drugs, the hospital will become liable for the physician's actions. Suspending the physician's privileges will satisfy the hospital's obligation to remove the physician.

The emergency suspension of a physician's privileges creates a special problem between the hospital and the patient. In a teaching hospital, where the patients have many primary physicians (or, in the view of some critics, no primary physician), the problem can be easily handled by diplomatically shifting the burden the care to another staff member. Suspension of privileges is also fairly simple in HMOs, where the responsibility for the patient's care is shared by many physicians. However, these two situations are exceptional. In most cases, the primary relationship is between the patient and the physician. The patient seeks care from the physician, who then admits the patient to the hospital. The patient would be justifiably upset to find that the treating physician has lost hospital privileges. The patient's wish, or even demand, to be treated by the physician does not obviate the hospital's liability for any injury that may occur as a result of the physician's negligence.

The inability of the patient's wishes to absolve the hospital from liability has two roots. The first root is the public policy that a person should not assume the risk of the consequences of negligence. This prohibition is necessary because of the unequal bargaining position of the parties in most health care transactions. In the medical situation, a patient often has little choice of physicians during an acute illness. The physician would, of course, like to have the patient agree not to sue if the care is unsuccessful. If the patient could be asked to absolve the physician of liability for negligent actions, society would lose a major control mechanism over the quality of medical care. The patient would suffer by having to choose between receiving medical care with no recourse for a negligent injury and not receiving the medical care. These problems have been weighed (by the courts) against the right of the patient to contract freely with the physician. The courts have ruled that, since the parties seldom have equal bargaining power (one party is not free to reject the unsatisfactory contract) and because the private enforcement assumption of the risk of negligence in the medical contract.

The second root is the hospital's duty to ensure the qualification of its medical staff. In the situation discussed here, the emergency suspension of privileges, the hospital is clearly on notice that the physician is impaired. The hospital's duty to monitor the medical staff is a nondelegable duty. The patient cannot be allowed to assume the responsibility for judging the physician's capabilities. In the same sense, the patient cannot be asked to bear the burden of a hospital's door with a nonstaff physician, the hospital (except in certain emergency circumstances) would not allow that physician to admit the patient to the hospital. In this situation, the hospital's duty is to protect the patient from improper care. The problem is the same if the patient is already hospitalized. If the hospital has notice that the physician is impaired, it has a duty to suspend that physician's privileges.

Once the decision to suspend privileges has been made, the physician's patients must be notified at once. The matter should be discussed with the patients, who should be asked if they want to be treated by another medical staff member. If the patient and another staff member are agreeable, new consent forms can be signed, and the responsibility of caring for the patient can be transferred. The person who talks with the patient--either another medical staff member or an administrator (unless there is a nurse the patient especially trusts)--should be careful to explain that the physician has been incapacitated by an illness or accident and can no longer care for patients. It is not necessary to elaborate on the possible hazards of allowing the physician to continue practicing.

The patient who refuses the substitution of a new physician--either in the case of an absent physician or a physician on emergency suspension--is a special problem. The hospital cannot discharge a patient who needs care. A medical staff committee should determine if it is medically appropriate to discharge the patient from the hospital. If it is appropriate to discharge the patient, this will solve the problem of substituting physicians. If it is not appropriate, the hospital must balance its duty to care for the patient against the patient's right to choose a physician. In almost all situations, the patient will eventually allow the substitution of physicians if the matter is carefully discussed so that the patient understands that it is in the patient's best interest. This may require the chief of the medical staff or the chief administrator to spend time with the patient, but this situation is rare enough that it merits such an effort. An alternative is to have the impaired physician appoint someone to take over that physician's patient care duties. While the patient may be dissatisfied with the assignment, it is legally acceptable for a physician to arrange for another physician (with appropriate privileges) to cover the former's practice. If the hospital bylaws specify that all members of the medical staff must designate someone to care for their patient's when they are unable to, the problem of physician substitution will be lessened.

While many health care providers who work in hospitals are independent contractors (i.e., not direct employees of the hospital), many others work directly for the hospital. Because the hospital is liable for the negligence of their employees, a malpractice victim would be entitled to sue the hospital for malpractice, in addition to suing the negligent hospital employee him/herself.

Now, let's look at the different people that may be involved in a medical malpractice case, and where legal liability might fall.

Physicians

Most cases of physician negligence fall into one of the following categories:

• misdiagnosis
• negligence affecting pregnancy and childbirth
• mistakes in prescribing or administering medication
• surgical errors

If a physician who worked for the hospital was negligent in any of these tasks (or in any other task), the hospital would be liable along with the physician. It gets tricky with physicians, however. Many are independent contractors, not employees, so some investigation may be necessary (more on this below).

Nurses

Nurses owe patients an independent professional duty. Obviously, a nurse is not directly in charge of a patient’s medical care, but there are many tasks that nurses perform that are related to the patient’s care.

Some of the most important of a nurse’s tasks include monitoring and feeding patients and administering medications, among other things. Nurses can make mistakes amounting to negligence in any or all of those tasks. For example, a nurse can:

• fail to monitor a patient properly
• fail to take a patient’s vital signs at the proper times
• forget to take an important vital sign
• fail to enter the patient’s nursing record into the patient’s chart
• administer the wrong type of medication
• administer the wrong amount of medication
• administer the medication at the wrong time
• fail to check a bedridden patient for bed sores
• fail to respond to a patient’s call quickly enough
• fail to report suspicious symptoms and complaints to the physician in charge.

Any one of these failures can constitute negligence. If the nurse is an employee of the hospital, the nurse’s negligence constitutes the hospital’s negligence as well.

Therapists

Therapists -- whether they be physical, occupational, or mental health therapists -- can also be negligent. For example, a physical therapist might fail to follow a physician’s instructions properly or might manipulate a patient’s injured limb too strongly. Physical therapists have been known to actually re-break a bone or re-tear a muscle or tendon that the therapist was supposed to be rehabilitating.

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