ACDIS day1-20 track5-4 pres 0516-Hill-Sandoval Lo-f · Stephanie Hill‐Sandoval, MSN, RN CDI Specialist The Children’s Hospital of Philadelphia, Philadelphia, PA A Motivation‐Based

©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.

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Lucinda Lo, MDPhysician Advisor

Stephanie Hill‐Sandoval, MSN, RNCDI Specialist

The Children’s Hospital of Philadelphia, Philadelphia, PA

A Motivation‐Based Model for CDI Change: The Pediatric Physician and Five WIIFMs

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Articulate the challenges of physician engagement in a large academic children’s hospital

– Identify 5 different motivational forces impacting collaboration and compliance with your physicians

– Implement 2 strategies to enhance physician engagement with your CDI goals

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CHOP at a Glance

• 535‐bed children’s hospital

• > 29,000 admissions

• > 25,000 annual inpatient and outpatient surgeries

• > 88,000 annual emergency department visits

• More than 1.1 million outpatient visits

• Patients from more than 50 nations

• More than 640,000 square feet of research space


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• Started in November 2014

• 5% APR‐DRG reimbursement

The Children’s Hospital of PhiladelphiaCDI Program

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CDI Education Training

All pediatric registered nurses with specialized training

• Education

–Consultant group–Coding boot camp

–Monthly education moments

– Staff orientation–Grand rounds

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CDI and HIM Relationship Building

• Monthly meetings held with the HIM leadership department

• EMR (Epic) CDI and coder communication


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Staffing Mix and Workflow

•4 full‐time CDIS•1 physician advisor

• 40‐patient caseload• 3–4 inpatient services• 20 daily concurrent chart review

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CHOP Medical Staff

CHOP is home to

more than 3,000

physicians, fellows, residents, &

nurse practitioners

who provide care for our patients

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MD Perceptions About Documentation

“No one looks at my note anyway”

“No one ever died from note‐apenia”

“Writing notes is the last thing I do because it has the least impact on me, my patients, my fellow doctors, and

my career”


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References

• Driveby Daniel H. Pink

• Switchby Chip and Dan Heath

• Leading Changeby John Kotter

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1.Navigate to the event Agenda in the main menu

2. Tap the name of the current session to view the session details page

3. Tap Polls

4. Tap the name of the poll

5. Tap your answerchoice and then tap Submit

Steps for Attendees to View/Answer POLLING QUESTIONS

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• What would you offer as the most appealing motivation for your colleague to embrace a change of practice?

– Money. More money

– Praise and feedback

– Compliance/rules

– Moral integrity/“greater good” than self

– Interesting or challenging for the person

Polling Question 1


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The HospitalistAn Official Publication of the Society of Hospital Medicine

The national median annual salary in 2010:

Internal medicine hospitalists seeing adult patients make

22% more than

pediatric hospitalists seeing children.

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1: Impact on Patient Experience

How will better

billing notes

improve the medical care for

MY PATIENT???

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Improving Patient Experience

A child’s fear and anxiety:

• Child life support for phlebotomy, IV placement, and medical procedures

• Pet therapy

Parental fear and anxiety:

• Trained staff for hands‐on teaching and feedback

• Use actual medical supplies to learn and practice with


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Impact of MRI Mock Scanner

Risk inherent to anesthesia and sedation

Cost of a mock MRI scanner is ~$10,000

Currently 43% of children scheduled

with sedation are able to complete the study WITHOUT sedation when supported by practice and distraction techniques

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2: Personal Impact of Documentation

How does

my physician note

impact

my reputation

???

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The Washington PostThe Washington Post: July 2015


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3: To Better Their Medical Field

Your note can improve pediatrics.

You are contributing

data

to your medical field with every

note

you write!

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Quality of Research in Your Medical Field

IncompleteDocumentation

In

Unreliable & uncertain results

Out

=

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Poster From National Pediatric Hospitalist Medicine Conference


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Poster From National Pediatric Hospitalist Medicine Conference

Summary of conclusions

• Neither 2012 KID nor 2012 NEDS show any decrease in hospital utilization for patients with obesity

• Because KID and NEDS are billing data sets and evidence shows obesity is undercoded, our results may be conservative estimates

• OR, some increase might be from increased attention to proper coding

• Providers should utilize an alternate source to recognize and counsel about obesity

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National pediatric databases: 8,100,000 resultsPediatric surgical databases: 1,980,000 results

• AHRQ: Health Care Cost & Utilization Project

• KID: Kids Inpatient Database • PHIS: Pediatric Health

Information System

• NDNQI: National Database of Nursing Quality Indicators

• NHSN: National Healthcare Safety Network

• NRC: National Research Center

• VPS: Virtual PICU Systems

• UNOS: Transplant Data• SPS: Solutions for Patient

Safety

• STS: Society of Thoracic Surgeons

• NCDR: National Cardiovascular Data Registry

• Children Oncology Group• ORYX: Joint Commission

Pediatric Databases and Registries

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4: Physician Stake in Their Institution

How does my physician

note

impact my

hospital

???


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Institutional Reputation

• Peer hospital rankings

– Report cards for your institution

©2016 by The Children's Hospital of Philadelphia, all rights reserved

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Medicare.gov—Hospital Compare

Hospital of University of Pennsylvania

PA

Thomas Jefferson University Hospital

PA

National rate

Death rate for stroke patients

No different than the national rate

Worse than the national rate

14.8%

Death rate for pneumonia patients


Better than the national rate

11.5%

Death rate for heart failure patients


Better than the national rate

11.6%

Rate of unplanned readmission after hip/knee surgery

Not available Worse than the national rate

4.8%

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5: Institutional Culture and Mission

• C‐suite

• Clinical affairs: Monthly meeting of division representatives

• Division chief meeting

• Review with clinical affairs representative

• Education & feedback tailored to division


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Pathway to Compliance

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• How do you best communicate with your medical team?

– Face‐to‐face/medical rounds

– Email

– Phone

Polling Question 2

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Personal Responses to Clarifications

• “Is the severity of illness really unclear?”

• “Is it necessary for us to amend these notes?”

• “Don't agree.”


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Education Planning

• Institutional education

• Division‐specific education

• Resident education

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Institutional Education

©2015 The Children’s Hospital of Philadelphia, All Rights Reserved • 16CHOP0053/1845/09‐15

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Division Education

• Division provider education

– 1:1 provider education

– Medical rounds

– Service‐specific presentations


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What Is the Difference?

Before query After query

Diagnoses • Dehydration• Reflux• Bradycardia

• Dehydration• Reflux• Bradycardia

Queried diagnoses

25% weight loss Severe malnutrition

APR‐DRG 251 IBD 251 IBD

SOI 2 (moderate) 3 (major)

ROM 1 (minor) 2 (moderate)

Relative weight0.56 0.79

JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS December 2014 Volume 114 Number 12

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Engaging the Residents

• Brainstorming session on how to get buy‐in from pediatric residents

– Report card

– Praise and kudos

– Resident presentation

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Incentives for Resident Engagement

• Attending and residents receive clarifications

• Candy

• Availability

• Brief teaching sessions


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Resident Report Card

NameType of

clarification Division

Escalation needed?

Attending notified

Kudos sent

BL Pulmonology yes

SK Obesityseverity

Generalpediatrics

No KW

HG Cytopenia Oncology No JR

JE Malnutrition severity

Adolescent No BZ

AA Anemia cause

Hematology No KC

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Just‐in‐Time Education

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Service‐Specific Education


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Aligning Our Message

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Overall CMI Improvement

2015

2014


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Overall SOI Improvement

2015

2014



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Updated Clarification

Dr. XXXXXX

According to your notes, the below diagnoses, signs, and/or symptoms were documented. In order to capture accurate risk of mortality and severity of illness, a more specific condition might apply to this patient.

The medical record reflects the following clinical data:

• Progress note from 12/28: “Most recent Hgb 7 on 12/24, down from 9.1 on 12/22. Transfused 10ml/kg packed RBC on 12/25 for anemia, murmur, and tachycardia, with subsequent resolution of tachycardia.”

Based on your clinical judgment of the clinical indicators outlined above, please clarify if the patient demonstrates:

o Acute blood loss anemia

o Chronic blood loss anemia

o Acute on chronic blood loss anemia

o Anemia of chronic systemic disease (not CKD)

o Other, please specify _________________

o Clinically undetermined

If you agree, for compliance purposes, please carry the diagnosis you choose forward into your progress notes and discharge summary. If you disagree, please hit “REPLY” and note “don’t agree.”

Thank you,

Mickey Mouse, RN, BSN, Clinical Documentation Improvement Specialist

(267) 426‐3698, office

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Physician Responses After Education

“Thank you very much for the reminder!”

“Agree—can call it acute respiratory failure and will accordingly amend my note.”

“Thanks for clarifying.”

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Malnutrition: Model Example

I. Patient

II. Mastery: Experts

III. Research: Pathway and QI

IV. Education: Feedback

V. Mission & culture


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Opportunity for Change

Change in medical guideline

American Society for Parental and Enteral Nutrition (ASPEN)

Clinical guidelines for malnutrition

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Mastery of Malnutrition

• Clinical nutritionists

• Physician representatives from GI, adolescent, general pediatrics, and oncology

• CDI

• EHR/EPIC

• QI

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Malnutrition Clinical Pathway



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Research, Education, & Culture

QI: EHR order set

Use for educational reference and feedback

One best practice for our patients

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Impact of Anemia & Malnutrition

• 16‐year‐old with 15 days of menorrhagia

• On admission has anemia with hemoglobin 2.8

• Hypotensive

• Receives multiple RBC transfusions

• Dietitian note: Erratic eating patterns, will often go days without eating. Patient only consumes 47% of estimated caloric needs. Recommend start malnutrition protocol for moderate malnutrition.

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Impact: Anemia & Malnutrition

Before query After query

Diagnoses • Excessive menstruation• Blood transfusion• Hypotensive

• Excessive menstruation• Blood transfusion• Hypotensive

Queried diagnoses

• Malnutrition • Anemia

• Moderate malnutrition• Anemia due to acute blood loss from menorrhagia

APR‐DRG 663 (other anemia) 663 (other anemia)

SOI 2 (moderate) 3 (major)

ROM 2 (moderate) 2 (moderate)

Relative weight

0.58 0.86


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CMI for Malnutrition

2015

2014


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SOI for Malnutrition

2015

2014


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In Closing

• Creating a climate for change

• Engaging and enabling your organization

• Implementing and sustaining change



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Thank you. Questions?

[email protected]@email.chop.edu

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.

Documents

ACDIS day1-20 track5-4 pres 0516-Hill-Sandoval Lo-f · Stephanie Hill‐Sandoval, MSN, RN CDI Specialist The Children’s Hospital of Philadelphia, Philadelphia, PA A Motivation‐Based