How ChristianaCare Improved Its PSIs

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The process involves a multi-step review.

Physicians take the Hippocratic Oath in medical school to “do no harm.” Despite their best intentions, however, many physicians sometimes unwittingly trigger a patient safety indicator (PSI) through their documentation. The Agency for Healthcare Research and Quality (AHRQ) developed the PSIs to evaluate for instances of harm and based their interpretation on the presence and/or absence of certain ICD-10 codes.  

It is unreasonable to expect physicians to know all the thousands of inclusion and exclusion codes that are updated yearly. A key factor in managing PSIs is a multi-disciplinary review that involves physicians, clinical documentation improvement (CDI) staff, and coding professionals.

ChristianaCare has strived for achieving “zero harm,” and has been fortunate to have the support of a robust data analytics and benchmarking team. In 2019, publicly available data showed that we were purportedly performing several standard deviations worse than the national mean on PSI-3 and PSI-90 as a whole. When we brought this back to our clinical leadership, we quickly realized that this data was not reflective of the high-quality care being delivered by our caregivers daily. Clinical care delivery is only one element of the process of clinical quality reporting. Equally important is accurate representation through documentation and coding. We knew we had plenty of opportunity to improve on the latter. 

The first step in developing a multi-disciplinary process for PSI, and any type of pre-bill hold, is to ensure alignment. PSIs have been embraced as a core safety metric by a multitude of external organizations, including but not limited to the Centers for Medicare & Medicaid Services (CMS), Leapfrog, Healthgrades, and Vizient.  

In addition, organizations may face financial penalties through the incorporation of the PSI-90 composite into the CMS Hospital Acquired Conditions Program and the CMS Value-Based Purchasing Program. Our performance on externally reported ranking programs and the associated financial penalties served as our platform for change.   

We were able to convince our finance team that letting accounts receivable float while we scrutinize the chart was worth the wait, and a 48-hour turnaround time was agreed upon. If physicians did not respond to queries that had a quality impact, we built an escalation process that rose up to our system’s chief medical officer.   

Next, we had to show our clinicians what they had to gain from engaging in this work. At our institution, many departments use PSIs as a metric in Ongoing Provider Performance Evaluation (OPPE) for re-credentialing. Additionally, we shared with them the reports showing that we were underperforming compared to our peer hospitals. Once we shared the individual and organizational objectives, our clinicians and clinical leadership quickly embraced this effort.   

Lastly, we needed to engage our coding team. We considered our coding team as central to this effort since they were ultimately the last caregivers to lay eyes on the claim before it is submitted. We also allayed their fears regarding clinical validation by having a dedicated CDI nurse reviewer and dedicated CDI physician advisor. Having understood the great responsibility they had in this process, and seeing the newfound support, they too quickly came on board. We now had complete alignment among all elements of our revenue cycle. Our goal was to make sure not a single potential PSI chart was final-coded until it was reviewed by all members of this team. 

The heart of our process involves a multi-step review. Our coding software flags potential PSI cases, and these are put on a pre-bill hold. These are then sent to a CDI reviewer who evaluates the case and proposed codes against the most recent version of the AHRQ PSI indicators document. If an exclusion code has been missed by the coding software, a query is sent to the coding team to see if this can be captured. If a PSI persists, at this stage it is sent to our CDI physician advisor for additional review. Upon recommendation of the physician advisor, a clarification query is drafted and sent. Every case is discussed with the discharging physician before the query is sent, to make sure they understand the choices and the reason for the query. If a query persists at this stage, it is escalated to our senior leadership team for review. If a PSI is cleared at any stage, it is released. If a PSI persists after senior leadership review, it is final-coded with a communication to the clinical team to evaluate for clinical improvement opportunities. PSI data is reviewed monthly to make sure our coded claims match our externally reported claims.   

This process has delivered tremendous results. We have seen our PSI-90 scores decrease precipitously. We can now reliably say that these metrics are an accurate reflection of the care being delivered at our organization. Our physicians and clinical leaders now have complete confidence in our data, and this allows our quality team to engage in conversations about clinical opportunities for improvement. 

Any organization seeking to improve PSI data overall has to ensure the integrity of documentation and coding processes.

Programming note: Listen to Dr. Varadarajan Subbiah report this story live today on Talk Ten Tuesdays at 10 a.m. EST.


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