COCOA:
A multi-disciplinary collaboration to
reduce HACs through appropriate
documentation
Nancy Rae Ignatowicz, RN, MBA, CCDS
Provena Health, System Manager Clinical Documentation
Nancy.Ignatowicz@Provena.org
Audience
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Physicians
Infectious disease physicians
Nurses
Coders
Epidemiologists
Infection control practitioners
Other
I am glad you came to
hear the stories behind
the slides!
• How many of you have had quality or infection
control tell you that you coded the chart wrong?
• How many of you have had quality or infection
control dictate to you what you should be telling
the physician in a query?
• How many of you have had quality or infection
control want you to question a physician’s
documented diagnosis?
There are competing
guidelines, rules,
regulations, and
definitions depending on
which discipline you are
from.
Agenda
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Multi-disciplinary collaboration
Health information management: coding
Infection control practitioners
Infectious disease physicians
Impact of HACs (Immediate/long-term: financial, P4P,
VBP, etc.)
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Res Ipsa Loquitur
CAUTI~FMEA
CLABSI~PDSA
Process flow maps
Multi-disciplinary Collaboration
CDI and reporting of patient safety data
Ensuring documentation is present to
reduce or eliminate the inappropriate
reporting of a healthcare-acquired condition
(HAC)
Communication and Collaboration
Sharing data institutes and builds an
environment for collaboration of internal
partners and external customers.
Fiscal management
Information systems
Infection control
Infectious disease physicians
Epidemiologist (PhD)
Medical staff
Risk management
Material/supply management
Nursing
Quality management
Patient
Education
CMO
Health information management,
clinical documentation, etc.
COCOA
Charting Obvious Conditions On Arrival
Today’s focus will be on:
• CAUTI (catheter-associated urinary tract infections)
• CLABSI (central line–associated blood stream
infections)
Public Report Cards:
Where Do the DATA Come From?
Reporting of CMS’ HACs are identified via ICD-9CM codes and modifiers as those conditions
which are reasonably preventable and able to be
identified via coded information.
The Infection Control HAI (healthcare-associated
infection) surveillance report is manually submitted
and can include data not reported via ICD-9-CM
codes such as diagnostic results, which may
contradict what the provider documented.
Coding
BASED ON PROVIDER’S DOCUMENTED
CLINICAL INTERPRETATION
Cannot code from diagnostic results
Must be documented by an approved provider
Must meet the criteria to be coded as a PDx/ODx
and POA
•“Y” yes POA ~ will be paid
•“N” not POA ~ will not be paid
•“U” not determinable if POA ~ will not be paid unless death or AMA
•“W” clinically not possible to determine POA ~ will be paid
CDC Infection Control Criterion:
CAUTI
• Looks at diagnostic results, not clinical S&S
• Fever does not qualify as a symptom for UTI
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for IC reporting
If catheter discontinued >48H, may not be
reported as CAUTI
Colony count may affect reporting
If >2 species, may not be reported
Not all organisms qualify as an IC CAUTI
(e.g., candiduria)
Infectious Diseases Society of
America: CAUTI
• Classic S&S that denote a symptomatic UTI are
not always useful for catheterized patients;
having said that, S&S such as FEVER, rigors,
AMS, malaise, lethargy, pain, etc., with no other
identifiable source may indicate a CAUTI
• Acknowledge gaps in our knowledge about
CAUTI; burden for diagnosis is based on the
CLINICAL JUDGEMENT of the treating
physician
• Recognizes funguria (candiduria) as one of
the most common pathogens for a
nosocomial UTI
CDC Infection Control Criterion:
CLABSI
• Use information from other sources besides
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provider documentation
Select units and defined time frames
Can use microbiology reports, pharmacy
reports, communications from nursing staff, etc.
Must be an IC recognized pathogen (exclude
common skin contaminants); looks for laboratory
confirmation
Purulent phlebitis; +catheter tip; -BC; not a BSI
per CDC
Infectious Diseases Society of
America: CLABSI
• CLABSI can originate from the catheter (i.e., tip,
hub, lumen); a positive peripheral BC is needed
for Dx, but a positive peripheral BC can be
delayed by 2H compared to from the line
• A CLABSI due to coagulase-negative staph
frequently has FEVER alone but may also have
catheter site redness. Coag-neg staph CLABSI
may resolve with removal of the catheter alone
and NO antibiotic treatment.
• Antibiotics should be initiated based on
CLINICAL CLUES
Financial Impact
Immediate
–AR/DNFC
–Case-specific reimbursement
• If another MCC/CC documented in
medical record, financial anticipated
reimbursement may not be affected
Why the renewed
interest from quality
directors?
Financial Impact
Long term
– Hospital Inpatient Quality Reporting
Program required hospitals to begin
submitting HAI data on Jan. 1, 2011; if a
hospital does not participate, it will receive
a 2% reduction in its annual CMS
payment in 2012
– Marketing: HAC data will be found on CMS’
Hospital Compare website
– P4P, VBP, third-party contractuals
Theory of Res Ipsa Loquitur
The plaintiff will not need to prove the case,
as the medical record will speak for itself by
indicating the condition was not present on
admission.
Document to avoid civil torte
OR
How much should the check be written for?
Impact: Transparency/Marketing
• Physician and hospital report cards
– Clinical components may be defined by disease
• LOS
• Cost per case/CMI adjusted
• SOI
• ROM/RAM
• Age
• Complications
– P4P, VBP, etc.
Pay for Quality,
Not Quantity
CAUTI: FMEA
Failure Modes and Effects Analysis:
Even though we did not have an actual problem,
we used this as an opportunity to be proactive in
improving our processes by assessing for areas
that could go wrong.
Infection control, quality, nursing, education,
medical staff, material/supply management,
information systems, risk, etc.
CAUTI:
COCOA Nursing POA Education
Inpatient: STROKE
DRG 63: HAC
Healthcare-acquired CAUTI
DRG 62: POA
CAUTI
present on admission
$7,875.78
$10,059.17
1981: CDC had 242 recommendations to prevent CAUTIs
2000: CDC estimates CAUTI may increase LOS by 1–4
days
CLABSI: PDSA
Plan-Do-Study-Act
A negative trending was identified in our
outpatient dialysis unit Apply lessons learned
to inpatient area
Patient, fiscal management, infection control,
quality, nursing, education, medical staff,
material/supply management, risk, etc.
CLABSI (CABSI):
COCOA Nursing POA Education
Inpatient: Pneumonia d/t Klebsiella
DRG 179: HAC
DRG 177: POA
Healthcare-acquired
CLABSI
CLABSI
present on admission
$7,687.81
$10,672.67
2002: CDC has 111 practices to prevent CLABSI
2000: CDC estimates a CLABSI increases LOS by
7–21 days
Process Flow Maps
Flow maps outlining our process for
potential HAC investigation and the way we
use it to keep our HAC DNFC (discharge not
final coded) down
Concurrent Process
CONCURRENT: Documentation specialists
look at select charts concurrently for
clarity and specificity in codeable
documentation. If a suspected HAC is
identified, the team is alerted.
CDN may query, if only POA clarification
needed; otherwise, consultation with the
team
Collaboration and Communication
CONCURRENT POTENTIAL HAC
C
O
M
M
U
N
I
C
A
T
I
O
N
Documentation nurse discovers potential HAC
OR
Infection control nurse, care manager, etc. notifies
documentation nurses of potential HAC
(phone/e-mail documentation)
Documentation nurse reviews chart for POA
documentation per coding guidelines and
notifies team as indicated; may query for
POA
POA
determination
made
NOT
POA
Documentation nurse notifies quality, risk,
and infection control, as appropriate
YES POA
Review
completed, as
NOT a HAC
C
O
O
R
D
I
N
A
T
I
O
N
Regardless Whether POA Is in
Question
Quality and/or infection
control may discuss
with physician
regarding diagnosis of
CAUTI or CLABSI!
Post-Discharge Process
• POST-DISCHARGE: Each case (all-payer) is
evaluated by a documentation specialist to
determine whether it is an actual HAC or
whether there are indications that the condition
was POA. IC/quality also review chart, and
IC/quality or CMO queries the physician if
needed.
• CDN may query, if only POA clarification
needed; otherwise, consultation with the team
• Collaboration and Communication
POST-DISCHARGE POTENTIAL HAC
B
E
F
O
R
E
HIM: Health information management notifies
documentation nurse of potential HAC
Documentation nurse reviews chart for POA documentation per coding
guidelines and, if not POA, notifies quality/infection control; cases are
reviewed regardless of immediate payment implications
POA
determination
YES
POA
F
I
N
A
L
Not a HAC
Review
completed
made
B
I
L
L
NOT
POA
Quality/infection control
reviews chart; team discusses
case; query written
Collaborative
decision is
made: (goal
48 hours)
AGREE or
AGREE to
Disagree
HIM codes
chart per
coding
guidelines
Coding Collaboration
We code only what is consistently
documented in the medical record that
meets coding guidelines for reporting PDx
or ODx and POA
Most of the time these are queries for
SOI/ROM
HIM coders and CDNs are integral parts of
the POA/HAC team
Agree to Disagree
• Coding needs a provider’s consistent
DOCUMENTED clinical interpretation of
the significance of a result/condition in
order to code and apply modifiers per
coding guidelines.
• Infection control may use non-provider
information and they look for laboratory
confirmation, which may contradict what
the treating physician documented.
Agree to Disagree
We know we will not always agree, so we have
agreed to disagree. We know ahead of time what
our data will be, and we are able to explain any
discrepancies between the different reports.
All disciplines follow their rules and regulations for
coding and reporting.
GOAL:
48 hours so that AR/DNFC is not delayed
Patient Safety
• Failing to connect the dots to realize an actual
or potential problem exists (FMEA or PDSA)
• Failing to report the findings to all the
appropriate team members
• Failing to do the follow-up and connect the
dots with your stakeholders
• Failing to analyze what your data mean …
If you are not part of the solution, are you part
of the conspiracy?
Ultimate Goals of HAC
Communication and Collaboration
Risk reduction & prevention
+ Performance excellence
+ Financial stability
= PATIENT SAFETY and
accurate HAC reporting
What We Have Discussed
• Differences between what can be coded and
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what IC reports as a HAI
Multidisciplinary communication/collaboration
Immediate and long-term impact of a HAC
(financial, P4P, VBP, etc.)
CAUTI ~ FMEA
CLABSI ~ PDSA
Res Ipsa Loquitur
Process flow maps
We at Provena Health are
fortunate to have two clinical
documentation nurses who
formerly worked as infection
control nurses.
Gina.Schultz@Provena.org
Deborah.Phillips@Provena.org
They were not able to be
here today, but I want to
acknowledge their extensive
expertise and contributions to
today’s session.
2011 HAC CMS Resources
• www.federalregister.gov
Federal Register,
Vol. 75, No. 157; Monday, August 16, 2010;
Rules and Regulation (on pages 50084–50085
is the list of the HAC ICD-9-CM codes)
• www.cms.gov/HospitalAcqCond/downl
oads/HACFactsheet.pdf
• www.cms.gov/MLNProducts/download
s/wPOAFactSheet.pdf
National Healthcare Safety Network
“January 1, 2011, NHSN will be the tool used by facilities
electing to participate in the CMS HAI IPPS Hospital
Inpatient Quality Reporting Program, formerly known as
Reporting Hospital Quality Data for Annual Payment
Update (RHQDAPU). As part of that program, central line–
associated bloodstream infection (CLABSI) data from
each facility’s adult and pediatric intensive care units and
neonatal intensive care units will be reported to NHSN and
shared with CMS. Each facility’s data will also be included
in CMS’ Hospital Compare tool, which publicly reports
hospital performance in a consistent and unified manner.”
www.cdc.gov/nhsn/cms-welcome.html
Additional CAUTI Information
• www.cdc.gov/HAI/ca_uti/uti.html
• www.cdc.gov/nhsn/pdfs/pscManual/
7pscCAUTIcurrent.pdf
• www.cdc.gov/nhsn/forms/57.114_UTI_
BLANK.pdf
• www.journals.uchicago.edu/doi/pdf/
10.1086/650482
Additional CLABSI Information
• www.cdc.gov/HAI/bsi/bsi.html
• www.cdc.gov/nhsn/PDFs/pscManual/
4PSC_CLABScurrent.pdf
• www.cdc.gov/nhsn/forms/57.108_
PrimaryBSI_BLANK.pdf
• www.journals.uchicago.edu/doi/pdf/
10.1086/320001
Any Questions?
Thank you