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Just a few years ago, clinicians and administrators at Cedars-Sinai Medical Center in Los Angeles were questioning the usefulness of quality measures based on hospital inpatient administrative claims data, such as the ´óÏóÊÓƵQuality Indicators (QIs). With successful clinical improvement processes already in place, clinicians discounted the accuracy of using a claims-based measure for case identification. However, as these kinds of data became more widely adopted and publicly reported, Cedars-Sinai set out to refine and improve their QI reporting process.

Several factors influenced the decision at Cedars-Sinai to implement the ´óÏóÊÓƵQI Toolkit after its release in 2012. One consideration was the Centers for Medicare & Medicaid Services’ use of the ´óÏóÊÓƵQIs in public reports of hospitals’ performance and in future value-based purchasing programs. Joe Kim, M.D., M.P.H, Associate Medical Director of Quality Improvement at Cedars-Sinai, and his colleagues recognized that the toolkit would enable them to make the data used for those measures more reliable and clinically accurate. More importantly, they would be able to use the data to pinpoint areas in which clinical care could be improved.  "What started out as a documentation and coding improvement effort," said Dr. Kim, "became an essential way for us to identify potential safety concerns about quality and safety and improve our performance over time."

Cedars-Sinai has successfully used the QI Toolkit to accomplish three important objectives:

• Getting support across the institution for the use of the ´óÏóÊÓƵQIs.
• Improving documentation and coding.
• Gathering data in "real time" to identify and address issues with clinical care.

Getting Buy-In at All Levels

One of the first steps at Cedars-Sinai was to convince administrators, clinicians, and staff of the value of the ´óÏóÊÓƵQIs as a key element of clinical quality improvement. "The toolkit provided a strategic framework for making a case for this work," noted Dr. Kim. His team used the toolkit’s sample presentations to senior leadership to understand the relevant governance issues and to get the visibility they needed. The prioritization matrixes also helped the team put the data into a larger context and gain the needed buy-in to move this project forward.

The QI Toolkit also supported the team’s efforts to get buy-in from staff, including coding managers and auditors, as well as physicians. Dr. Kim said that engaging medical staff has been a significant challenge, in part because they were not familiar with the strict guidelines that coders must follow and did not fully appreciate how their documentation and coding practices affected reporting of the ´óÏóÊÓƵQIs.  The toolkit’s resources were used to assist in improving both the care and the accuracy of the documentation that reflects that care.

Closing the Gap Between Clinical Documentation and Clinical Reality

Dr. Kim credits the ´óÏóÊÓƵQI Toolkit with helping identify inaccuracies between the care delivered and how it is documented at Cedars-Sinai.  Before the hospital adopted the toolkit, it was hard to determine if there were documentation or true clinical care issues. This made it challenging for clinicians to determine whether and how to improve care delivery.

For instance, when Cedars-Sinai received quarterly reports from University HealthSystem Consortium® (UHC) that indicated a potential problem, such as higher than expected cases of accidental punctures or lacerations during procedures or pressure ulcers, the team would review the data from that time period. But the "noise" resulting from documentation issues made it difficult to gain consensus that they had a clinical problem that needed to be fixed. Often the cases identified did not accurately reflect all the clinical complexities. The toolkit gave Cedars-Sinai a framework for getting all the relevant players on board and developing a consensus for improving both the documentation of clinical care and the accuracy of the coding.

Providing Real-Time Data

The team also concluded that the retrospective reviews were not the most efficient way to address the issues; a process to identify QI cases in "real time" was essential.  The toolkit offered a step-by-step process for reproducing data and benchmarking performance internally. As a result, Cedars-Sinai can now generate its own "real-time" data at the time of discharge rather than waiting months for retrospective data. With these data in hand, the QI team can intervene when needed to correct issues with documentation and share timely information to address clinical problems.

Selected ´óÏóÊÓƵQIs are now part of an institutional weekly report, which is shared with all service providers and clinical and operational leadership. The report has become an important hospital metric that is designed to drive action at the unit level. Everyone is held responsible for actions to mitigate potential patient harm. Task forces that include staff from many different departments and disciplines are assigned to carry out a "leave-no-stone-unturned" search for opportunities to prevent harm across the board. All ideas are important and no ideas are deemed too small or too unusual to consider.

Cedars-Sinai has virtually eliminated central line-associated bloodstream infections (CLABSIs) by implementing a number of recommendations from its CLABSI task force. Its "Code Sepsis" project has helped ensure rapid response to sepsis cases, and its antimicrobial stewardship programs (ASPs) have contributed to significant reductions in C. difficile cases. The Healthcare-Acquired Pressure Ulcers and Falls Prevention task forces have achieved similar successes.

Embracing the ´óÏóÊÓƵQI Toolkit as a Welcome Roadmap

"We felt like we were pretty evolved with QI initiatives; however, we learned there were more opportunities," said Dr. Kim. He and his colleagues found that the toolkit gave them a roadmap for tackling what turned out to be a daunting project: not just improving the reported results, but actually driving change in the institution. Using the ´óÏóÊÓƵQI Toolkit gave the team at Cedars-Sinai confidence in both its data and its ability to identify and address real issues in clinical care.