There has recently been a tremendous increase in emphasis on quality and patient safety within American medicine. Much of this is due to an improved ability to look at and evaluate results from large numbers of patients and determine “best practices” shown to improve outcomes.
In addition, there has been a large push from governmental regulatory bodies to adhere to these practices. In some instances, financial penalties will be imposed for those who do not follow them.
As urologists and nephrologists involved in clinical practice, adherence to all of these measures can seem daunting.
However, in partnership with hospitals and professional societies, most of these measures can be incorporated into daily practice. Some, such as the meaningful use of electronic medical records, apply to all physicians regardless of specialty. Showing that a problem list is maintained and reviewed, prescriptions are handled electronically, and so forth allows better coordination of care and is rewarded by the government.
Other process measures may be more specific to surgical versus medical specialties. For example, there are a number of surgical care improvement project measures that deal with the perioperative period for which the urologist is responsible. Appropriate antibiotic selection and timing (given within one hour prior to surgery and stopped within 24 hours after surgery), venous thromboembolism prophylaxis, as well as continuation of beta-blockers perioperatively (in those patients who take them) are some of the process measures that are tracked and reported.
In addition to maintaining the highest level of quality and appropriate prophylaxis, documentation is crucial as well. For example, a small serosal tear on the bowel encountered during a lysis of adhesions may be coded as the accidental laceration “patient safety indicator” (PSI) if the surgeon does not document within the operative note that it was “insignificant.” Oftentimes coders are trained to look for “red flag” terms and if found will code it as a PSI when in reality it was insignificant.
Thus, whenever using the words laceration, puncture, tear, and so on, it is important to clarify if it was insignificant or perhaps was actually part of the intended procedure. Good communication must exist between coders and physicians to make sure that only what is a true PSI is coded as such. Asking for and personally reviewing a sampling of what was coded as PSI or unmet surgical care improvement project (SCIP) measures in the past year gives clinicians a better sense of how this is being done and the degree of reliability of the coding.
In addition, making sure appropriate documentation is performed on admission will prevent clinicians from being held responsible for something that certainly could not have developed within that hospital stay but had not been documented as “present on admission.” For example, a patient with the stage 3 decubitus ulcer noted on their third day in the hospital obviously did not develop that condition during that admission, but if this is not documented on the intake, it may be listed as a clinician’s PSI.
Staying current with relevant society guidelines, being aware of the reportable measures, documenting accurately, and communicating well with coders and hospital staff involved in quality and patient safety should allow physicians to maintain high quality patient results and have good reportable outcomes.
Howard B Goldman, MD, is affiliated with the Center for Quality and Patient Safety, Glickman Urological & Kidney Institute, Cleveland Clinic