7-2 Final Project Submission Organizational Performance Initiative

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Southern New Hampshire University *

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IHP 430

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May 15, 2024

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Final Project Submission: Organizational Performance Initiative 1 7-2 Final Project Submission: Organizational Performance Initiative IHP 430: Healthcare Quality Management Southern New Hampshire University Professor Sharonda Ward 02/18/2024
Final Project Submission: Organizational Performance Initiative 2 I Organizational Problem According to AAPC (2022), clinical documentation refers to the information entered in a medical record by a person in charge of a patient’s medical care. To ensure the meaningfulness of clinical documentation, it is essential for it to exhibit traits of reliability, consistency, timeliness, completeness, clarity, precision, and legibility, as these factors accurately depict the patient’s disease burden and the scope of services provided (AHIMA). The importance of clinical documentation lies in ensuring continuity of patient care and facilitating effective communication between healthcare providers. A lack of understanding important coding information and the use of vague language has made poor documentation a significant concern for providers and healthcare organizations. Who is using a health record and the purpose it serves determine the quality of clinical documentation. Documentation that lacks specifics can be considered poor documentation by both physicians and coding specialists. Inadequate documentation, Electronic Medical Records that lack narratives, and misinterpreting OASIS are the top three challenges in clinical documentation, as stated by Kelly (2021). The surge in data volume, complexity, and management leads to issues in clinical documentation. Additionally, there are challenges related to the utilization of non- specific documentation templates with inherent limitations. Moreover, the risk of documenting one patient’s information in another patient’s records (referred to as patient identification error) poses serious threats to patient safety, privacy concerns, incorrect clinical decision-making, increased costs for patients, providers, and payers.
Final Project Submission: Organizational Performance Initiative 3 II Evidence-Based Support Data that Supports the Existence of the Problem: In the 1984 case of Libby Zion, a New York college student, evidence-based data highlights challenges in clinical documentation. Following consultation with Zion’s family physician, the residents in the ER administered a sedative and painkiller, unaware of the dangerous contraindication with her antidepressants. Zions tragically suffered from cardiac arrest and ultimately lost their life due to this contraindication. This case primarily revolved around the legal consequences of doctors’ working hours and the level of monitoring provided by the ER staff to Zion. It highlights the importance of physicians having comprehensive and up-to-date medical histories when treating patients in the ER. Despite the fact that electronic medication reconciliation practices, which were not even conceivable in 1984, have become the norm today, the potential consequences of an incomplete patient record remain just as disastrous as they were back then (Butler, 2015). Way of Addressing the Problem in the Past: The problem has been solved through the inclusion of HIT education in the curriculum for aspiring physicians. The goal is to integrate seamlessly with current practices, leveraging IT expertise among the staff, conducting gap analysis using case mix index (CMI) comparisons, and ensuring continuous documentation updates. One of the main reasons for its requirement is to gather more detailed information about patients, while also aiming to improve communication channels among providers, clinical staff, healthcare personnel, and health organizations. This will assist in the sharing of patient information and the coordination of care. Electronic
Final Project Submission: Organizational Performance Initiative 4 physician’s orders (CPOE) is one information management system/patient care technology used to tackle this issue. It aims to decrease human errors, enhance clinical outcomes, coordinate care, improve practice efficiencies, and track data. Alotaibi and Federico (2017) listed several healthcare technologies, including CDS, E-prescribing, and EMR. Relevant Accreditation Standards, Safety standards, Compliance Standards, and Quality Initiatives: AHIMA’s Code of Ethics and the Standards for Ethical Coding form the basis of ethical standards for CDI professionals. The purpose of this standard is to ensure that clinical documentation is accurate, complete, and consistent. Additionally, it aims to facilitate the documentation of appropriate diagnoses, procedures, and other health service-related information. Furthermore, it helps organizations comply with internal reporting policies and procedures, and creates an environment that encourages honest and ethical reporting practices, ultimately leading to the production of accurate and reliable data (AHIMA, 2016). It is important to note the existence of the Healthcare Insurance Portability and Accountability Act (HIPAA) of 1996 Public Law 104-191 as another ethical standard. This act aims to enhance the efficiency and effectiveness of the healthcare system through the implementation of national standards for electronic health care transactions, code sets, unique health identifiers, and security (OCR, 2021). The purpose of HIPAA is to safeguard patient information, ensure patient safety, establish safety standards to prevent medical errors, and enhance patient outcomes.
Final Project Submission: Organizational Performance Initiative 5 III Performance Improvement Initiative Performance Improvement Plan: The practice of clinical documentation improvement (CDI) involves thoroughly assessing medical record documentation to ensure its comprehensive and precise nature (Aapc, 2022). CDI initiatives are driven by the goal of bridging the gap between clinical documentation and accurate coding, which involves reviewing diagnostic findings, disease processes, and identifying any missing information from the documentation (Aapc, 2022). In 2007, CDI programs/initiatives gained popularity when the Centers for Medicare & Medicaid Services (CMS) implemented Medicare Severity Diagnosis Related Groups (MS-DRGs). By implementing the MS-DRGs payment model within the Inpatient Prospective Payment System (IPPS), Medicare aims to optimize reimbursement and minimize compliance risks. This is accomplished by conducting a comprehensive evaluation of the inpatient medical record documentation and promptly seeking clarification from the provider whenever any ambiguous or incomplete information is detected, before the claim is submitted (Aapc, 2022). CDI, or Clinical Documentation Improvement, offers numerous benefits to healthcare organizations. These benefits include a notable increase in the accuracy of reimbursement, which ensures that healthcare providers receive the appropriate payment for their services. CDI also plays a crucial role in preventing penalties that may arise from default or non-compliance with regulations. Additionally, it helps prevent unsupported diagnoses from being included in insurance claims, ensuring that all submitted claims are valid and justified. Moreover, implementing CDI practices has been shown to contribute to a reduced readmission rate,
Final Project Submission: Organizational Performance Initiative 6 indicating that patients are receiving better care and experiencing improved health outcomes. Furthermore, CDI enhances care coordination among healthcare professionals, facilitating seamless communication and collaboration. By implementing CDI, organizations can also expect improved quality reporting, leading to better insights into patient outcomes and overall healthcare quality. Ultimately, the benefits of CDI in a healthcare organization are far-reaching and encompass financial, regulatory, and patient care aspects. In order for a CDI initiative to be successful, it is imperative to have a dedicated team lead who is responsible for maintaining compliance with policies and regulations, regularly reviewing and monitoring processes, and providing training and education to all personnel and stakeholders involved in the reimbursement process. This comprehensive approach ensures a higher level of specificity in the documentation process, which ultimately contributes to the success of the CDI initiative (EHRIntelligence, 2023). Quality Outcome Data: The Donabedian model classifies measures employed to assess and compare the quality of health care outcomes, or quality outcomes, into three categories: structure, process, and outcome. Providers’ ability to deliver quality care is determined by the capacity, systems, and processes they have in place, as indicated by structural measures of quality outcome. Take, for instance, the structural measures that pertain to providers’ capacity. These measures could include factors like the presence of board-certified or qualified physicians within the healthcare organization, the utilization of electronic health record (EHR) systems or medication order entry systems (MOES), and the provider-to-patient ratio (AHRQ, 2015). The efficiency of healthcare services can be negatively affected when there is a smaller number of providers available to treat patients, as there may not be enough physicians to promptly attend to all patients.
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