What's New in HCQM?

Breaking Down Silos: Documentation to Support Utilization Review, Quality, and CDI
Timothy Brundage, MD, CCDS
Medical Director / Chief Executive Officer - Brundage Group

I’d like to encourage physician advisors around the country to break down the silos that exist within hospital organizations. Physician advisors should be focused on much more than patient status assignment; they should be looking at the chart from a global perspective to accurately reflect the care provided. This perspective should supersede the utilization review department, the quality department and the CDI department.

The physician advisor should examine the chart to ensure that medical necessity is present while also ensuring the documentation supports accurate code assignment and the timeliness of the documentation supports the quality of care provided.

Only diagnoses that are captured Present On Admission (POA = Y or W) are used by Medicare to risk adjust expected mortality. The physician advisor should be keenly aware that mortality observed to expected rates are publicly reported. Our hospitals should provide the community with high-quality care that is reflected as such in the metrics.

Documentation is King
The physician advisor should be able to take a case review for medical necessity, which contains the documentation of cystitis and acute kidney injury with an acutely elevated Cr of 2, for example, and understand that this may or may not support inpatient status. If the physician advisor understands the global care provided to the patient, he or she should immediately work with the attending physician to document more effectively. If the acute kidney injury is explicitly linked to the cystitis, then the clinician should contemplate the diagnosis of severe sepsis based on SOFA.

This will immediately improve documentation that may potentially support inpatient status, support the appropriate DRG assignment to track expected resource consumption and track to the accurate expected mortality. The utilization management team is supported, the CDI team is supported, and the quality team is supported. Most important, the accurate picture of the patient is reported—and the patient is supported!

The JAMA article, The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), published in 2016, reports a 10% expected mortality when diagnosing (severe) sepsis using the SOFA criteria. This patient is sick, even more so than you may believe. (https://jamanetwork.com/journals/jama/fullarticle/2492881)

Strengthening the Role of the Physician Advisor
The role of a physician advisor is to support the clinician who is caring for the patient. The patient needs high-quality care and the clinician needs to be able to provide the care in the appropriate setting while also demonstrating to the community that he or she is providing high-quality care.

Physician advisors should be breaking down the silos within hospitals to advocate for global care and global tracking of high-quality care. They should get involved with the CDI team and the quality team, and make sure they are working with the utilization review team in a coordinated fashion.

It is not uncommon for me to go into a hospital and see the utilization review, CDI and quality teams working completely independent from one another, with very little communication.

The role of the physician advisor is to lead the global team toward the accurate portrayal and status of the patient, as well as the appropriate tracking of the quality of care that physicians are providing to the community.

And, I’d be remiss if I didn’t mention that this will also reduce the risk of denial if audited!


Learn more about the issues and join me for "Breaking Down Silos: Documentation to Support Utilization Review, Quality, and CDI " at ABQAURP’s 43rd Annual Health Care Quality and Patient Safety Conference in Clearwater Beach, FL on April 30-May 1, 2020. For more information and to register, visit www.abqaurp.org/AnnualConference.