Taking Aim at Mortality Scores
Clinical Documentation Improvement Nurses
Effecting a Positive Change
Suzanne Schultz, RN, CCDS
Claudia Baker RN, CCDS
www.FletcherAllen.org
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FLETCHER ALLEN HEALTH CARE
 Vermont’s academic medical center in alliance with the
University of Vermont in Burlington, Vermont
 562 beds
 Level 1 Trauma Center, Level 111 NICU, Children’s Hospital.
 Approximately 6,500 employees
 Staff of 900 physicians, 250 community physicians, 230
residents, 60 fellows
 Approximately 200 NP’s and PA’s collectively
 5 CDI Registered Nurses
www.FletcherAllen.org
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Objectives
 Clinical Documentation Improvement Program at FA
 CDI: Background and Process
 University Health Care Consortium: Partner in
Improvement
 Why is Mortality Important?
 UHC Mortality Ratio
 Mortality Case Study
 Closing statements
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Goals of Clinical Documentation Improvement
 Medical records are the foundation of any medical
institution because the record is a representation of
the patients, who are the very reason why we exist.
 Documentation that captures a patient’s true comorbidities, severity of illness and risk of mortality is
essential.
 The goal of CDI is high quality documentation that is
accurate, concise, clear, complete, reliable and in
accordance with the law.
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CDI Program at Fletcher Allen
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Initiated in October 2009
4 RN’s and one Director
Medical Director
3M consultants for 6 months, dedicated software
8 Inpatient Coders and Nurse Coding Supervisor as
Liaison.
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FLETCHER ALLEN CDI
 Focused Medical Record Review
 Query and Documentation Clarification: Standardized process
based on FA CDI policy, which abides by the guidelines of
AHIMA.
 CDI Education for Providers: Formal presentations to provider
groups that are tailored to their individual needs which
enhances relevance.
 Rounding with specific resident teams to provide on the spot
education and support.
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Documentation Clarification
 Lack of Clarity
 Lack of Specificity
 Conflicts with other documentation
 Please provide a diagnosis that corresponds with the
lab value of Na 123 documented in your progress
note on Oct 24 in Mrs. Jones’ medical record.
 Dear Provider, Please spell out what you mean by
AKI in your note on Mr. Smith on Oct. 24.
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Work Flow of CDI - Clarification Process
1. Provider documents initial assessment.
2. CDI reviews record.
3. Documentation is accurate /complete.
Next review date assigned.
4. If documentation requires clarification/specificity?
5. Query initiated and provider contacted.
6. CDI re-reviews record, documentation complete and accurate.
Next review date assigned.
7. Documentation is not complete- Patient discharged. Attending is
contacted about clarification.
8. Still not complete, CDI Medical Director Review.
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Mortality Data and the University Healthcare Consortium
 UHC is an alliance of the nations leading nonprofit academic
medical centers totaling 114 and 255 total affiliated hospitals.
 Comparing Fletcher Allen to other academic medical centers is
a more appropriate comparison than a broad national
comparison that doesn't reflect a similar patient population.
 The Expected Mortality is a calculated measure developed by
UHC and is based on “risk adjustment” information about FA
patients. Risk models are periodically recalibrated due to
reductions in LOS and mortality rates.
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Definition of Terms
 Severity of illness (SOI) is defined as the extent of organ system
derangement or the physiologic decompensation of a patient.
 Risk of mortality (ROM) provides a medical classification to estimate
the likelihood of in-hospital death for a patient. The ROM class is used for
the evaluation of patient mortality.
 Mortality Rate is total number of deaths.
 Observed to Expected Mortality(O:E) ratio is defined as the total
number of deaths compared to the total number of expected deaths based
on risk adjustments. Risk adjustments include patient-related age, gender,
or pre-existing conditions.
 Diagnosis-related group (DRG) is a system that classifies hospital
cases. DRG’s are used to determine how much CMS pays a hospital for
services.
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Why are Mortality Scores Important
 Hospital Report Cards are on the web and include mortality
data.
 Mortality rates are considered by the JCHO to be one of the
important indicators of quality.
 CMS, in the interest of promoting high quality , patient –
centered care and accountability, reports 30 day mortality
measures to the public.
 Mortality rates for Pneumonia, Heart Attack, and Congestive
Heart Failure are viewed as indicators of overall performance
for a hospital.
 CMS is collecting data now to establish Value Based
Purchasing (VBP) benchmarks.
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Severity of Illness and Risk of Mortality Metric
Level
Level
1
2
Severity
of Illness
Minor
Moderate
1
2
Risk of
Mortality
Minor
Moderate
3
Major
3
Major
4
Extreme
4
Extreme
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Mortality O:E Ratio
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Together and as a Team: Getting Closer to the Target
Measurable Improvement in Mortality Scores Realized
 Our Quality Improvement Consultant from the Jeffords
Institute for Quality, Pat Bouchard, HIM Coding Supervisor
Martha Sheehey and the CDI nurses identified opportunities to
take the mortality review process to another level.
 Based on a quality of care metric to drive improvements.
 February 2011 was the lowest monthly O:E value for mortality
to that date and was the
4th consecutive month
demonstrating a decline.
 This was significant.
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Mortality Case Study
 75 yo male, VNA called FA ED, patient not doing
well at home. Transported via amb w/ 100% NRB,
O2 sat 81%, 89% in ED. B/P 92/48-81/38, resp 2830, temp 101.2. PMH significant for COPD, CHF,
HTN, CAD, CKD, HLP. In ED, desaturated with
venti-mask O2 after nebulizer. CXR reveals bil
infiltrates/edema. BIPAP applied. IV hydration w/
B/P responding. Labs Na 148, K+ 5.6, Creat 2.30.
Admitted MICU w/ appropriate protocols. BLD draw
in 4 hours. Records show last ECHO 30% EF.
CODE STATUS: DNR/DNI. Bipap OK. Family to
come in.
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Clinical Documentation Comparison
Query
Opportunities
Query Outcomes
SOI /ROM Drivers
PNEUMONIA include
infecting organism ?
ACUTE RESPIRATORY
FAILURE
COPD
COPD EXACERBATION
specify acuity?
CHF
SOI 3/ ROM 2
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ACUTE ON CHRONIC
SYSTOLIC HF
DRG 195
SOI 4/ ROM 4 DRG 189
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In Closing
 Thank you for your time and attention.
 Thanks you to our Team Partners: Quality Consultant
Pat Bouchard; Martha Sheehey, Coding Liaison and
the HIM Staff; Dr. Norm Ward, Medical Director for
CDIP; FA Medical Staff and Residents, and the
Nursing Staff at FA.
 Contact: Suzanne Schultz by e-mail at
suzanne.schultz@vtmednet.org
 Claudia Baker by e-mail at
claudia.baker@vtmednet.org
www.FletcherAllen.org

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