Royal Hobart Hospital: Preparing Clinical Coding for ABF

Ben Spurr – PAS & Health Information Manager

Royal Hobart Hospital - Background

Major Acute Hospital for THO - South

Royal Hobart Hospital - Background

RHH is the Tertiary Referral Hospital for Tasmania

Served Hobart for over 200 years

First Opened in 1804

Is Australia’s second oldest Hospital

It has been on the current site since 1820.

Oldest current buildings on site date to 1939.

Royal Hobart Hospital - Background

Services a population of 240 000 people

550 Beds (460 overnight, 90 day stay)

Provides State-wide services such as cardiac surgery, neurosurgery, extensive burns treatment, hyperbaric medicine, neonatal and paediatric intensive care and high risk obstetrics.

Averages 65 000 separations per year

Royal Hobart Hospital

Undergoing $586 million redevelopment

RHH Redevelopment

Major Redevelopments include:

New Inpatient Precinct

New Outpatients Department

New DCCM (ICU)

New Integrated Cancer Centre

New Medical Imaging Facility

New Assessment & Planning Unit (APU)

New Production Kitchen

RHH prior to National Health Reforms and ABF

Historical Block Funding

Changing to ABF

Whole new focus on clinical coding & casemix funding

Patient Information Management Services (PIMS)

Clinical Coding Office

Clinical Classification & Information Department

9.48 Clinical Coding FTE

HIMAA certified clinical coders

Advanced: 8

Intermediate: 2

Basic: 1

Coding Manager

Coder Coder Coder Coder Coder Coder

Clinical Classification & Information Department

Health Roundtable peer Hospitals:

Average 13 FTE

Recruitment is extremely challenging

Although currently fully staffed

Clinical Coders sourced internally from previous administrative roles:

Clinical transcription

Ward Clerks

Medical Records

Offer staff Clinical Coding Experience:

Asses suitability to the role

Clinical Coding Training

Internal training (1:1 manager)

Aligned with experienced coding mentor (colleague)

HIMAA coding courses

At commencement often only completed terminology course

Undertake Basic HIMMA certificate on the job

Coding Workforce

Experienced coders approaching retirement

Reducing hours

0

1

2

3

4

5

6

7

20-29 30-39 40-49 50-59 60-69 70-79

Coding Workforce Age

Range

Coding Workforce challenges

Nil Career Progression Pathway

Due to organisational structure of Department

General Administrative Award

All one award

Basic vs Advanced = (same award)

Stagnation

Motivation for personal development

Interstate recruitment

Hampered by Tasmanian award.

Coding Workforce challenges

No Leave Coverage

No Overtime

No Contractors

No Casuals

High Long Service Leave accrual

Clinical Coding Audits

Prior to 2012/13 no internal audit program

Annual external coding Audit:

Random Sample of 100 records

8% DRG Change

2010 DHHS State-wide Clinical Coding Baseline Audit:

19% Recommended DRG change

19% Potential DRG Change

Recommended that THOs undertake a review of their clinical coding workforce and their capacity to meet the increasing demand.

Desired Department Structure

Coding Manager

Coder Coder Coder

Trainee

Auditor Educator

Internal Coding Audit Program

Previous Business Case to expand coding department:

5% improvement in coding - $14 million

At Creation of Audit program there was no Tasmanian ABF Model

Based on Round 14 NHCDC cost weights:

Creation of Audit Matrix

Each DRG Assigned an Audit Weight

DRG Audit Weight X DRG Count = Audit Score

Highest Audit Scores = Highest Audit Priority

LOS Criteria

Internal Coding Audit Program

Created an extract template to identify audit cases

Audit conducted at completion of monthly coding

Peer Audit Program

All Coders to be assigned cases for audit

Distributed by Coding Manager

Creating Audit Culture

Initial resistance / hesitance to peer audit

Peer audit Necessary due to resources:

Lack of auditor / educator position

Coding Manager time restrictions

Lack of familiarity with internal audits

Accustomed to yearly external audit process

Overcome initially with de-identification of original coder details

All appear to be coded by Coding Manager.

Monthly open forum to discuss results

Coding Results - example

Open discussion of all cases with any change

Primary tool for education purposes

Clinical Coding Audit Results

Results (2012/2013):

Platform for creation of further level of training

Platform for creation of Internal Coding Directives

Evidence for Business case for Auditor / Educator Position & Trainee positions.

Clinical Coding Audit Results

Over time the continual feedback and response from audit results has been seen as positive in continuing education

Differing opinions / interpretations of standards highlighted

3M Codefinder pathway discussions

Navigation of DMR & Source Systems

Monthly internal audits are business as usual

Coders have embraced audit culture – thirst for knowledge

Positive attitude to audit & wider discussion and dissemination of findings

Coder Education

Education for coders to create queries for clinicians

Weekly coder education sessions

Clinical coder queries

Clinical & Coding

Challenge scenarios for further discussion

Clinical in-services with clinical specialties

Admissions Policy

Admission criteria

Care types

Clinical Engagement prior to ABF

Clinical Engagement

Clinicians keen to learn about ABF

Think they get the money!

Accountable for their own activity

Clinical Champions

Oncology

Obstetrics

Respiratory

General Medicine

Cardiology

Anaesthetics

Paediatrics

Surgery – work in progress

Clinical Engagement (cont)

Clinical Documentation Guidelines for RHH

Specific to each RHH specialty

Distributed to unit heads

Based on the “Good Clinical Documentation Guidelines”

Regular Presentations to interns / RMO’s / UTas Medical Students

Documentation Requirements

Px Dx & Additional Diagnosis.

Care Type Changes

Clinical Coding & DRG’s

Clinical Engagement (cont)

Clinical in services

Coding to Clinical – Clinical to Coding

Requested due to topical issues

Clinician reports

Coder questions

Engagement with GP Liaison officers

Primary focus is to the GP’s

Strong focus on Documentation and Communication.

Clinical Engagement – Documentation Queries

Clinicians have improved their understanding of documentation requirements for clinical coding

Documentation Queries

DMR facilitates easier review and correspondence

Email queries & replies

Either screen shots or page reference

Evidence of replies scanned to DMR

Incomplete Coding Database

Episodes where coding is adversely impacted are captured in incomplete Coding Database:

Nil Discharge Summary available

Missing Notes

Missing Operation Notes

Admission criteria not met

Incorrect care typing

Monthly Coding Reports

Results from Incomplete Coding Database

Missing notes by ward / specialty

Incomplete discharge summaries by ward / specialty

Incorrect care type changes by ward / specialty

Clinical Query Response Rate

Reported to Group Managers Monthly

Trended by month

Ward / specialty (all above)

Discharge Specialty

Missing Entire Notes

Total Discharges Per

Specialty

% Missing Entire Notes Per Specialty

Addiction Medicine Count 2 19 10.5

Cardiology Count 1 137 0.7

Cardiothoracic Surgery Count

1 27 3.7

Gastroenterology Count 2 319 0.6

General Medicine Count 3 281 1.1

Interim Care 3 3 100.0

Geriatric Medicine Count 4 54 7.4

Gynae/Oncology Count 1 26 3.8

Neonatology Count 1 163 0.6

Oncology Count 2 251 0.8

Ophthalmology Count 4 36 11.1

Paediatric Medicine Count 2 132 1.5

Psychiatry Count 1 138 0.7

Respiratory Medicine Count

3 97 3.1

Rural GPs / primary care 5 66 7.6

Stroke Count 1 34 2.9

100.0 94.4

89.5 85.7

77.8 81.3 78.6 76.9 80.0

100.0

77.8

50.0

80.0

0.0

20.0

40.0

60.0

80.0

100.0

Percentage of Documentation Queries Resolved Per Month

Information Technology Projects Assisting Coding

Electronic Discharge Summaries

Training Delivery to clinicians - content

Legibility

Clinical Worklists

“incomplete summaries”

Statistical reports available

Completed Summaries messaged directly to DMR

DMR

Electronic Operation reports

Progress notes (limited at this stage)

ARIA

Real time clinical & admin data for Medical Oncology

Short coding turnaround times (real time clinical entry)

Information Technology (cont)

Future Developments

E-forms

Care type forms

Electronic operation reports (specialist)

Neurosurgery

DCCM / NICU

Clinical Systems

Auto CMV hours / progress notes / charts

Data / Coding edits

Business Intelligence Unit

DHHS

Challenges

Ageing workforce

Most experienced staff reducing hours

Approaching Retirement

Recruiting

Regional Area

Award Rate

Career pathway

Clinical Coding Auditor / Educator Position / Trainee position

Obtaining funding

Challenges

DHHS - Tasmanian Admissions Policy

Funding model = Financial Year

Admissions Policy = Calendar year

Clinical Coding Auditing from the DHHS

Awaiting release of State-wide Coding Action Plan

THO’s Requesting Coding Audits for quality improvement processes

Tasmanian Activity Based Funding Model

RHH exceeding Weighted Sep targets

No alternative public hospitals

N emphasis to audit to improve weighted separations at this time.

Questions?

Contact Details

Ben Spurr

PAS & Health Information Manager

Ph: 03 6222 6838

ben.spurr@dhhs.tas.gov.au