Best Care in Action: Multidisciplinary OB Services improvement team strengthens clinical documentation, ensures patient safety

Dec 20, 2016, 14:18 PM by KirstiAnn Clifford
The OB Services improvement team
Providing safe and effective patient care is the top priority for UTMB’s Department of Obstetrics and Gynecology.

So when they learned UTMB would face penalties of $2.5 million—due to new state rules for Medicaid reimbursement regarding Obstetrical cases for potentially preventable complications (PPCs)—it surprised many.

“The reason we are all at UTMB is because we believe in the care we give and the system that we have set up,” said Dr. George Saade, chief of Obstetrics and Maternal Fetal Medicine. “We are a tertiary care center that receives all the complicated cases for a reason, and that’s what we have dedicated our careers to. As soon as we heard there may be a problem with potentially preventable complications, we wanted to fix it right away.”

Saade and Dr. Gary Hankins, chairman of the Department of Obstetrics and Gynecology, worked with Mark Kirschbaum, RN, PhD, chief quality, safety and clinical information officer, to quickly convene a multiprofessional group including OB/GYN physicians, Quality Management staff and coders.

The first answer everyone wanted to determine was whether there were any actual safety issues or inappropriate care administered. In less than a month, the group conducted a review of more than 60 patient charts and found that the main problem revolved around clinical documentation, not direct patient care.

“We quickly validated that we didn’t have a clinical problem,” said Kirschbaum. “Our moms were receiving good care, but we weren’t taking the credit. That’s because the complexity of the patient wasn’t always listed in their documentation for billing and coding staff to accurately report encounters.”

For instance, if existing conditions aren’t documented before a patient is admitted, it may be counted against the hospital that billed the encounter. In the case of OB, the most common complication coded was hemorrhage. However, when the multidisciplinary OB Services improvement team dug a bit deeper, they found many women who experienced expected blood loss were not actually having clinically significant hemorrhages.

“In some cases, women may have arrived anemic and received a blood transfusion. But because their anemia was not documented when they were admitted, coders assumed the blood transfusion was the result of a hemorrhage,” said Jill Bryant-Bova, senior quality management specialist. “The coder is coming in behind and reading the medical record as it is stated. If the physician doesn’t document it, the coder can’t code it properly. We have a saying: ‘If it wasn’t documented, it wasn’t done.’”

Moving forward, the OB Services improvement team established a real-time documentation review process for potentially preventable complications, implemented Epic optimizations and trained faculty to reduce documented OB complications dramatically in a year’s time. The result: UTMB has gone from having incurred complication penalties of $2.5 million in 2014 and 2015, to none, as of Sept. 1.

“I am astonishingly proud,” said Kirschbaum. “The rallying cry was very effective and the respect at the table was high. When Drs. Saade or Hankins were speaking, everyone listened because we don’t understand clinical issues the way they do. When the coder was speaking, everyone listened to their expertise. It was interdisciplinary, respectful and every idea brought to the table was worth considering. It really did take a village.”

Saade emphasized that while fixing documentation was important, ensuring patient safety and providing Best Care was the No.1 priority.

“It’s really all about the patient,” said Saade. “Our first reaction was about our patients, not the documentation. The fact that PPCs are being tracked and we continue to review charts—it’s for the patient’s safety. I feel very ecstatic about UTMB’s response. It’s unique to have a place where an interprofessional group can meet frequently and work together to address an issue. Sometimes these meetings took hours, but it didn’t matter how much time it took because we wanted to make sure we were providing the best care possible.”

He added that the focus on patient safety in OB/GYN is not limited—several members of the team have also been reviewing and tracking other potential complications, such as infectious morbidity, and analyzing patient safety event reports that may uncover areas for improvement. There has also been work on OB potentially preventable readmissions.

Bryant-Bova said she is proud to have been involved in making a change and that she looks forward to sustaining Best Care.

“We ultimately made improvements in the quality of care that we are providing to patients,” she said. “This is a positive step and I’m sure we can transfer what we learned here into different departments and areas of UTMB.”