How to improve care quality and ensure fair reimbursement with interdisciplinary mortality review

Risk-adjusted mortality rates are key indicators of care quality. Hospitals focus on these metrics in an effort to improve patient outcomes, as well as to ensure fair reimbursement for their services.

While high risk-adjusted mortality rates can be an indicator of care quality issues, they can also result from non-care related issues. Possible contributing factors include incomplete or vague physician documentation of patient diagnoses and incorrect coding.

Interdisciplinary mortality review programs are a proven way to reduce mortality rates and improve care quality. Becker's Hospital Review recently spoke with Laura Triplett, director of health information management at Quincy-Ill.-based Blessing Health System. She shared lessons learned and best practices for establishing mortality review programs.

The origins of Blessing Health System's interdisciplinary mortality review program

Initially, Blessing Health System started a program to revitalize its clinical document improvement (CDI) program. A primary goal of this initiative was to ensure that the information in patients' medical records accurately reflected the severity of their condition. "We concentrated a lot on this area, which brought about improvement in our risk-adjusted mortality scores," Ms. Triplett said.

As a part of the CDI program, staff assessed the severity of illness ratings of deceased patients to determine whether the ratings appropriately correlated with outcomes. The group identified some disparities between the illness ratings and patient outcomes.

"We knew that we could be more proactive and working collaboratively looked like a good option," Ms. Triplett said. "We assembled an interdisciplinary team comprised of coding, performance excellence (quality department), and the physician advisor for the CDI team, who is also the Chief of Quality & Safety." 

This committee convenes weekly to review patient charts prior to final coding to ensure the documentation specificity is accurately reflected and complete in the patient’s medical record. If there are more cases than can be reviewed in the regular weekly meeting, the group schedules additional time. There is physician representation at every meeting.

Expanding the program and improving quality

Initially, Blessing Health System's interdisciplinary mortality review committee only assessed higher risk cases and cases where opportunities existed to clarify documentation to patient charts. The team found, however, that improvement opportunities existed in all patient charts.

"At the beginning of the program, we only reviewed a percentage of charts before final coding. Now, we review all of them," Ms. Triplett said. "Doing the work on the front end is more efficient. We no longer need to do as much rework on the backend, if documentation is further clarified after final coding."

The results have been positive. Blessing Health System has seen its risk-adjusted mortality score improve. The expected mortality rate continues to increase, due to the specificity provided in documentation that impacts the severity of illness and risk of mortality.  The actual raw mortality rate decreased as well. 

Best practices for implementing an interdisciplinary mortality review program

Blessing Health System attributes the success of its interdisciplinary mortality review program to three factors:

  1. Physician involvement leads to more effective interdisciplinary review. When the committee reviews mortality charts and identifies query opportunities, a physician on the team reaches out to the attending physician or the consulting provider on the case. "Instead of asking a CDI nurse or coder to contact physicians on the cases, we've found a lot of great success having a physician on our team serve as the direct point of contact," explained Ms. Triplett.
  1. Frequent team meetings are essential. Interdisciplinary mortality review committees must meet regularly, so chart reviews don't impact bill hold days or the hospital's DNFB (discharged not final billed) metrics. Teams should consider how holding charts and not coding them with the four-day DNFB window could affect the discharge.
  1. It's important to monitor key metrics. Interdisciplinary mortality review committees must evaluate the case mix index, as well as how the hospital's risk of mortality and severity of illness scores compare to those of peer organizations.

Conclusion

For hospitals on a journey of continuous improvement, interdisciplinary mortality review programs can be a useful tool for improving quality and reimbursements. These groups often spur innovation in other areas, as well. As Ms. Triplett observed, "Our interdisciplinary group has uncovered additional improvement opportunities. The organization's physician liaison recently created a group for long-term care that now meets quarterly with representatives from community nursing homes."

Risk -adjusted mortality rates are key indicators of care quality. Hospitals focus on these metrics in an effort to improve patient outcomes, as well as to ensure fair reimbursement for their services. While high risk-adjusted mortality rates can be an indicator of care quality issues, they can also result from non-care related issues. Possible contributing factors include incomplete or vague physician documentation of patient diagnoses and incorrect coding.
Interdisciplinary mortality review programs are a proven way to reduce mortality rates and improve care quality. Becker's Hospital Review recently spoke with Laura Triplett, director of health information management at Quincy-Ill.-based Blessing Health System. She shared lessons learned and best practices for establishing mortality review programs.
The origins of Blessing Health System's interdisciplinary mortality review program
Initially, Blessing Health System started a program to revitalize its clinical document improvement (CDI) program. A primary goal of this initiative was to ensure that the information in patients' medical records accurately reflected the severity of their condition. "We concentrated a lot on this area, which brought about improvement in our risk-adjusted mortality scores," Ms. Triplett said.
As a part of the CDI program, staff assessed the severity of illness ratings of deceased patients to determine whether the ratings appropriately correlated with outcomes. The group identified some disparities between the illness ratings and patient outcomes.
"We knew that we could be more proactive and working collaboratively looked like a good option," Ms. Triplett said. "We assembled an interdisciplinary team comprised of coding, performance excellence (quality department), and the physician advisor for the CDI team, who is also the Chief of Quality & Safety."
This committee convenes weekly to review patient charts prior to final coding to ensure the documentation specificity is accurately reflected and complete in the patient’s medical record. If there are more cases than can be reviewed in the regular weekly meeting, the group schedules additional time. There is physician representation at every meeting.
Expanding the program and improving quality
Initially, Blessing Health System's interdisciplinary mortality review committee only assessed higher risk cases and cases where opportunities existed to clarify documentation to patient charts. The team found, however, that improvement opportunities existed in all patient charts.
"At the beginning of the program, we only reviewed a percentage of charts before final coding. Now, we review all of them," Ms. Triplett said. "Doing the work on the front end is more efficient. We no longer need to do as much rework on the backend, if documentation is further clarified after final coding."
The results have been positive. Blessing Health System has seen its risk-adjusted mortality score improve. The expected mortality rate continues to increase, due to the specificity provided in documentation that impacts the severity of illness and risk of mortality. The actual raw mortality rate decreased as well.
Best practices for implementing an interdisciplinary mortality review program
Blessing Health System attributes the success of its interdisciplinary mortality review program to three factors:
1. Physician involvement leads to more effective interdisciplinary review. When the committee reviews mortality charts and identifies query opportunities, a physician on the team reaches out to the attending physician or the consulting provider on the case. "Instead of asking a CDI nurse or coder to contact physicians on the cases, we've found a lot of great success having a physician on our team serve as the direct point of contact," explained Ms. Triplett.

2. Frequent team meetings are essential. Interdisciplinary mortality review committees must meet regularly, so chart reviews don't impact bill hold days or the hospital's DNFB (discharged not final billed) metrics. Teams should consider how holding charts and not coding them with the four-day DNFB window could affect the discharge.

3. It's important to monitor key metrics. Interdisciplinary mortality review committees must evaluate the case mix index, as well as how the hospital's risk of mortality and severity of illness scores compare to those of peer organizations.
Conclusion
For hospitals on a journey of continuous improvement, interdisciplinary mortality review programs can be a useful tool for improving quality and reimbursements. These groups often spur innovation in other areas, as well. As Ms. Triplett observed, "Our interdisciplinary group has uncovered additional improvement opportunities. The organization's physician liaison recently created a group for long-term care that now meets quarterly with representatives from community nursing homes."

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