Health Systems Management Network can perform an operational assessment of your institution's data-gathering and documentation practices from admitting through billing. The result will be a management plan including detailed action items that will enable your institution to continuously improve the quality of clinical data, its documentation, billing practices and medical records.
The ultimate goals of documentation are to provide accurate and timely clinical
data and complete billing information for all hospital services provided to
the patient. From admission through final billing to record storage, the professional
staff of Health Systems Management Network can conduct an operational assessment
of clinical-data generation, its documentation and the flow of that documentation.
This research will take the form of retrospective reviews of a significant
number of representative cases and concurrent reviews that track "live
patients" through the system. These reviews will locate steps in the
process and areas or circumstances where omissions, inefficiencies and inaccuracies
affect the quality of care and/or ultimate reimbursement. Interviews are performed
with operational and financial managers and staff , observations of staff
documentation practices are made and reviews of policies and protocols are
performed.
Typical Clinical Data and Document Reviews
CONCURRENT REVIEW OF DOCUMENTATION - includes a complete
assessment of clinical data and documentation quality, timeliness and completeness.
DOCUMENTATION ASSESSMENT - develops a thorough understanding of the
documentation process and staff practices to ascertain the consistency between
services rendered and services billed, the severity of the case and the meeting
or exceeding of all standards by final documentation.
NURSING DOCUMENTATION - determines the effectiveness of the nursing
staff in assuring that complications, labs, meds and other ancillaries are
documented correctly.
CODING/DRG ASSIGNMENT RETROSPECTIVE REVIEW - performed on a representative
case mix including those which fall into the window for rebilling.
ADMITTING - performed to assure accurate initial recording of information.
MASTER PATIENT INDEX - evaluates problems associated with the controlof
accounts and the accuracy and availability of the medical record during subsequent
patient visits.
RECORD COMPLETION - analyzes all procedures, policies and staff skills
and behaviors that affect the entire post- discharge documentation process.
REGULATORY DOCUMENTATION REQUIREMENT - for example, establishment of
procedures to meet new HCFA attestation regulations.
BILLING - determines how each step and function in the billing process
contributes to the speed and accuracy of the final bill.
RECORD INFRASTRUCTURE - establishes how well the documentation management
is supported by dictation and transcription, active and inactive medical record
file management, inpatient/outpatient charting, and electronic systems.
The results of our reviews will be analyzed for problems that may lead to
quality of care issues, duplicated or unnecessary procedures, uncaptured charges,
excessive time before billing and potential for lost revenue due to audit.
A Continuous Quality Improvement Plan for clinical data and documentationwill
result. Each goal of the recommendations will be listed as a critical path
with benchmarks for completion by certain dates. This plan, although firmly
based on the facts discovered at your institution, will benefit from our wide
experience in the industry. In close consultation with managers and staff,
we will design system improvements and programs to correct deficiencies in
clinical data and documentation. Priority and focus will be on revenue improvement
issues such as accuracy of coding and DRG assignments, thecompleteness of
record at time of discharge, bill processing time, and the ability of the
documentation quality to meet or exceed standards.
We will recommend staffing requirements if needed and detail educational needs
for existing staff members who will implement new practices and develop any
revised job descriptions, organizational structures or competency models required.
Staff and policies must be supported by efficient operational documentation
processes, which in turn are supported by data processing systems. Our data
processing experts will recommend appropriate changes in hardware and software.
As required to assure a smooth transition to new procedures and systems,
the professionals of Health Systems Management Network can lead or assist
in the implementation of all recommendations. By using progress charts supplied
in our final report, management will be able to assess progress and performance
by task and responsibility.
Six to
twelve months after submission of the management plan, we can perform a brief,
iterative analysis designed to evaluate progress toward goals
