Royal Hobart Hospital:
Preparing Clinical Coding
for ABF
Ben Spurr – PAS & Health Information Manager
Royal Hobart Hospital Background
Major Acute Hospital for THO - South
Royal Hobart Hospital Background
RHH is the Tertiary Referral Hospital for Tasmania
 Served Hobart for over 200 years
 F...
Royal Hobart Hospital Background
 Services a population of 240 000 people
 550 Beds (460 overnight, 90 day stay)
 Provi...
Royal Hobart Hospital
 Undergoing $586 million redevelopment
RHH Redevelopment
 Major Redevelopments include:
 New Inpatient Precinct
 New Outpatients Department
 New DCCM (ICU)

...
RHH prior to National Health
Reforms and ABF
 Historical Block Funding
Changing to ABF
 Whole new focus on clinical coding & casemix funding
Patient Information Management
Services (PIMS)
Clinical Coding Office
Clinical Classification &
Information Department
Coding
Manager
Coder

Coder

Coder

Coder

 9.48 Clinical Coding FTE
 H...
Clinical Classification &
Information Department
 Health Roundtable peer Hospitals:
 Average 13 FTE

 Recruitment is ex...
Clinical Coding Training

 Internal training (1:1 manager)
 Aligned with experienced coding mentor (colleague)

 HIMAA ...
Coding Workforce
 Experienced coders approaching retirement
 Reducing hours

Coding Workforce Age
Range
7
6
5
4
3
2

1
0...
Coding Workforce challenges
 Nil Career Progression Pathway
 Due to organisational structure of Department

 General Ad...
Coding Workforce challenges
 No Leave Coverage
 No Overtime
 No Contractors

 No Casuals
 High Long Service Leave acc...
Clinical Coding Audits
 Prior to 2012/13 no internal audit program
 Annual external coding Audit:
 Random Sample of 100...
Desired Department Structure
Coding
Manager

Auditor

Coder

Educator

Coder

Coder

Trainee
Internal Coding Audit Program
 Previous Business Case to expand coding department:
 5% improvement in coding - $14 milli...
Internal Coding Audit Program

 Created an extract template to identify audit cases
 Audit conducted at completion of mo...
Creating Audit Culture
 Initial resistance / hesitance to peer audit
 Peer audit Necessary due to resources:
 Lack of a...
Coding Results - example

 Open discussion of all cases with any change
 Primary tool for education purposes
Clinical Coding Audit Results
 Results (2012/2013):

 Platform for creation of further level of training
 Platform for ...
Clinical Coding Audit Results
 Over time the continual feedback and response from audit
results has been seen as positive...
Coder Education
 Education for coders to create queries for clinicians
 Weekly coder education sessions
 Clinical coder...
Clinical Engagement prior to ABF
Clinical Engagement


Clinicians keen to learn about ABF
 Think they get the money!
 Accountable for their own activity...
Clinical Engagement (cont)
 Clinical Documentation Guidelines for RHH
 Specific to each RHH specialty

 Distributed to ...
Clinical Engagement (cont)
 Clinical in services
 Coding to Clinical – Clinical to Coding

 Requested due to topical is...
Clinical Engagement –
Documentation Queries
 Clinicians have improved their understanding of
documentation requirements f...
Incomplete Coding Database

 Episodes where coding is adversely impacted are
captured in incomplete Coding Database:
 Ni...
Monthly Coding Reports
 Results from Incomplete Coding Database
 Missing notes by ward / specialty
 Incomplete discharg...
Discharge Specialty

Addiction Medicine Count
Cardiology Count
Cardiothoracic Surgery
Count
Gastroenterology Count
General...
Percentage of Documentation Queries Resolved
Per Month
100.0
80.0

60.0
40.0
20.0

0.0

100.0
94.4

100.0
89.5

85.7

77.8...
Information Technology Projects
Assisting Coding


Electronic Discharge Summaries
 Training Delivery to clinicians - con...
Information Technology (cont)
 Future Developments
 E-forms
 Care type forms

 Electronic operation reports (specialis...
Challenges
 Ageing workforce
 Most experienced staff reducing hours

 Approaching Retirement

 Recruiting
 Regional A...
Challenges
 DHHS - Tasmanian Admissions Policy
 Funding model = Financial Year
 Admissions Policy = Calendar year

 Cl...
Questions?

Contact Details
Ben Spurr
PAS & Health Information Manager

Ph: 03 6222 6838
ben.spurr@dhhs.tas.gov.au
Ben Spurr - Royal Hobart Hospital - CASE STUDY : Royal Hobart Hospital: Preparing Clinical Coding for ABF
Ben Spurr - Royal Hobart Hospital - CASE STUDY : Royal Hobart Hospital: Preparing Clinical Coding for ABF
Ben Spurr - Royal Hobart Hospital - CASE STUDY : Royal Hobart Hospital: Preparing Clinical Coding for ABF
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Ben Spurr - Royal Hobart Hospital - CASE STUDY : Royal Hobart Hospital: Preparing Clinical Coding for ABF

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Ben Spurr, PAS & Health Information Manager, Royal Hobart Hospital presented this at the 5th Annual Clinical Documentation, Coding and Analysis Conference. This event is the only case study led conference in Australia looking solely at clinical documentation, coding and analysis.

For more information, please visit http://www.healthcareconferences.com.au/clinicaldocs

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Ben Spurr - Royal Hobart Hospital - CASE STUDY : Royal Hobart Hospital: Preparing Clinical Coding for ABF

  1. 1. Royal Hobart Hospital: Preparing Clinical Coding for ABF Ben Spurr – PAS & Health Information Manager
  2. 2. Royal Hobart Hospital Background Major Acute Hospital for THO - South
  3. 3. Royal Hobart Hospital Background RHH is the Tertiary Referral Hospital for Tasmania  Served Hobart for over 200 years  First Opened in 1804  Is Australia’s second oldest Hospital  It has been on the current site since 1820.  Oldest current buildings on site date to 1939.
  4. 4. Royal Hobart Hospital Background  Services a population of 240 000 people  550 Beds (460 overnight, 90 day stay)  Provides State-wide services such as cardiac surgery, neurosurgery, extensive burns treatment, hyperbaric medicine, neonatal and paediatric intensive care and high risk obstetrics.  Averages 65 000 separations per year
  5. 5. Royal Hobart Hospital  Undergoing $586 million redevelopment
  6. 6. RHH Redevelopment  Major Redevelopments include:  New Inpatient Precinct  New Outpatients Department  New DCCM (ICU)  New Integrated Cancer Centre  New Medical Imaging Facility  New Assessment & Planning Unit (APU)  New Production Kitchen
  7. 7. RHH prior to National Health Reforms and ABF  Historical Block Funding
  8. 8. Changing to ABF  Whole new focus on clinical coding & casemix funding
  9. 9. Patient Information Management Services (PIMS)
  10. 10. Clinical Coding Office
  11. 11. Clinical Classification & Information Department Coding Manager Coder Coder Coder Coder  9.48 Clinical Coding FTE  HIMAA certified clinical coders  Advanced: 8  Intermediate: 2  Basic: 1 Coder Coder
  12. 12. Clinical Classification & Information Department  Health Roundtable peer Hospitals:  Average 13 FTE  Recruitment is extremely challenging  Although currently fully staffed  Clinical Coders sourced internally from previous administrative roles:  Clinical transcription  Ward Clerks  Medical Records  Offer staff Clinical Coding Experience:  Asses suitability to the role
  13. 13. Clinical Coding Training  Internal training (1:1 manager)  Aligned with experienced coding mentor (colleague)  HIMAA coding courses  At commencement often only completed terminology course  Undertake Basic HIMMA certificate on the job
  14. 14. Coding Workforce  Experienced coders approaching retirement  Reducing hours Coding Workforce Age Range 7 6 5 4 3 2 1 0 20-29 30-39 40-49 50-59 60-69 70-79
  15. 15. Coding Workforce challenges  Nil Career Progression Pathway  Due to organisational structure of Department  General Administrative Award  All one award  Basic vs Advanced = (same award)  Stagnation  Motivation for personal development  Interstate recruitment  Hampered by Tasmanian award.
  16. 16. Coding Workforce challenges  No Leave Coverage  No Overtime  No Contractors  No Casuals  High Long Service Leave accrual
  17. 17. Clinical Coding Audits  Prior to 2012/13 no internal audit program  Annual external coding Audit:  Random Sample of 100 records  8% DRG Change  2010 DHHS State-wide Clinical Coding Baseline Audit:  19% Recommended DRG change  19% Potential DRG Change  Recommended that THOs undertake a review of their clinical coding workforce and their capacity to meet the increasing demand.
  18. 18. Desired Department Structure Coding Manager Auditor Coder Educator Coder Coder Trainee
  19. 19. Internal Coding Audit Program  Previous Business Case to expand coding department:  5% improvement in coding - $14 million  At Creation of Audit program there was no Tasmanian ABF Model  Based on Round 14 NHCDC cost weights:  Creation of Audit Matrix  Each DRG Assigned an Audit Weight  DRG Audit Weight X DRG Count = Audit Score  Highest Audit Scores = Highest Audit Priority  LOS Criteria
  20. 20. Internal Coding Audit Program  Created an extract template to identify audit cases  Audit conducted at completion of monthly coding  Peer Audit Program  All Coders to be assigned cases for audit  Distributed by Coding Manager
  21. 21. Creating Audit Culture  Initial resistance / hesitance to peer audit  Peer audit Necessary due to resources:  Lack of auditor / educator position  Coding Manager time restrictions  Lack of familiarity with internal audits  Accustomed to yearly external audit process  Overcome initially with de-identification of original coder details  All appear to be coded by Coding Manager.  Monthly open forum to discuss results
  22. 22. Coding Results - example  Open discussion of all cases with any change  Primary tool for education purposes
  23. 23. Clinical Coding Audit Results  Results (2012/2013):  Platform for creation of further level of training  Platform for creation of Internal Coding Directives  Evidence for Business case for Auditor / Educator Position & Trainee positions.
  24. 24. Clinical Coding Audit Results  Over time the continual feedback and response from audit results has been seen as positive in continuing education  Differing opinions / interpretations of standards highlighted  3M Codefinder pathway discussions  Navigation of DMR & Source Systems  Monthly internal audits are business as usual  Coders have embraced audit culture – thirst for knowledge  Positive attitude to audit & wider discussion and dissemination of findings
  25. 25. Coder Education  Education for coders to create queries for clinicians  Weekly coder education sessions  Clinical coder queries  Clinical & Coding  Challenge scenarios for further discussion  Clinical in-services with clinical specialties  Admissions Policy  Admission criteria  Care types
  26. 26. Clinical Engagement prior to ABF
  27. 27. Clinical Engagement  Clinicians keen to learn about ABF  Think they get the money!  Accountable for their own activity  Clinical Champions  Oncology  Obstetrics  Respiratory  General Medicine  Cardiology  Anaesthetics  Paediatrics  Surgery – work in progress
  28. 28. Clinical Engagement (cont)  Clinical Documentation Guidelines for RHH  Specific to each RHH specialty  Distributed to unit heads  Based on the “Good Clinical Documentation Guidelines”  Regular Presentations to interns / RMO’s / UTas Medical Students  Documentation Requirements  Px Dx & Additional Diagnosis.  Care Type Changes  Clinical Coding & DRG’s
  29. 29. Clinical Engagement (cont)  Clinical in services  Coding to Clinical – Clinical to Coding  Requested due to topical issues  Clinician reports  Coder questions  Engagement with GP Liaison officers  Primary focus is to the GP’s  Strong focus on Documentation and Communication.
  30. 30. Clinical Engagement – Documentation Queries  Clinicians have improved their understanding of documentation requirements for clinical coding  Documentation Queries  DMR facilitates easier review and correspondence  Email queries & replies  Either screen shots or page reference  Evidence of replies scanned to DMR
  31. 31. Incomplete Coding Database  Episodes where coding is adversely impacted are captured in incomplete Coding Database:  Nil Discharge Summary available  Missing Notes  Missing Operation Notes  Admission criteria not met  Incorrect care typing
  32. 32. Monthly Coding Reports  Results from Incomplete Coding Database  Missing notes by ward / specialty  Incomplete discharge summaries by ward / specialty  Incorrect care type changes by ward / specialty  Clinical Query Response Rate  Reported to Group Managers Monthly  Trended by month  Ward / specialty (all above)
  33. 33. Discharge Specialty Addiction Medicine Count Cardiology Count Cardiothoracic Surgery Count Gastroenterology Count General Medicine Count Interim Care Geriatric Medicine Count Gynae/Oncology Count Neonatology Count Oncology Count Ophthalmology Count Paediatric Medicine Count Psychiatry Count Respiratory Medicine Count Rural GPs / primary care Stroke Count Missing Entire Notes Total Discharges Per Specialty % Missing Entire Notes Per Specialty 2 1 19 137 10.5 0.7 27 319 281 3 54 26 163 251 36 132 138 3.7 0.6 1.1 100.0 7.4 3.8 0.6 0.8 11.1 1.5 0.7 97 66 34 3.1 7.6 2.9 1 2 3 3 4 1 1 2 4 2 1 3 5 1
  34. 34. Percentage of Documentation Queries Resolved Per Month 100.0 80.0 60.0 40.0 20.0 0.0 100.0 94.4 100.0 89.5 85.7 77.8 81.3 78.6 76.9 80.0 80.0 77.8 50.0
  35. 35. Information Technology Projects Assisting Coding  Electronic Discharge Summaries  Training Delivery to clinicians - content  Legibility  Clinical Worklists  “incomplete summaries”  Statistical reports available  Completed Summaries messaged directly to DMR  DMR  Electronic Operation reports  Progress notes (limited at this stage)  ARIA  Real time clinical & admin data for Medical Oncology  Short coding turnaround times (real time clinical entry)
  36. 36. Information Technology (cont)  Future Developments  E-forms  Care type forms  Electronic operation reports (specialist)  Neurosurgery  DCCM / NICU  Clinical Systems  Auto CMV hours / progress notes / charts  Data / Coding edits  Business Intelligence Unit  DHHS
  37. 37. Challenges  Ageing workforce  Most experienced staff reducing hours  Approaching Retirement  Recruiting  Regional Area  Award Rate  Career pathway  Clinical Coding Auditor / Educator Position / Trainee position  Obtaining funding
  38. 38. Challenges  DHHS - Tasmanian Admissions Policy  Funding model = Financial Year  Admissions Policy = Calendar year  Clinical Coding Auditing from the DHHS  Awaiting release of State-wide Coding Action Plan  THO’s Requesting Coding Audits for quality improvement processes  Tasmanian Activity Based Funding Model  RHH exceeding Weighted Sep targets  No alternative public hospitals  N emphasis to audit to improve weighted separations at this time.
  39. 39. Questions? Contact Details Ben Spurr PAS & Health Information Manager Ph: 03 6222 6838 ben.spurr@dhhs.tas.gov.au

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