Clinical Coding Target

Transcription

1 Clinical Coding Target Situation The Finance and Performance Committee recently discussed the Welsh target for Clinical Coding, which is that 95% of all episodes be coded within 12 weeks of the episode end date. This target has been in place for a number of years, and the cause of considerable frustration in the desire for up to date information for clinical review, performance and financial management. As there was no Informatics representative at the meeting, a follow up report was requested, with a request to improve upon the national target Background In England, due to Payment By Results, the Clinical Coding service received additional support to achieve a coding target of 3 working weeks. While it is difficult to compare the English target with Wales (no PBR, no transfer to Community hospital), the current target does not support timely information, for funding, performance or clinical decision making. Given that BCU undertakes about inpatient episodes each month, achieving the target for any given month could still leave nearly 900 (5%) episodes uncoded. In 2010 BCUHB allocated additional revenue to support the Clinical Coding process, with a view to improving the 12 week target, which in turn would support improved data quality, clinical engagement, performance and financial information. The revenue is being used to: Appoint 3 WTE Band 5 Clinical Coders/Auditors. Appoint 2 WTE Band 4 Clinical Coders. Appoint 5.5 WTE Clerical Support staff. Appoint agency staff working at weekends to reduce the backlog (East, Centre, and now West). Achieve 98% within 4 weeks by March 2012 The remaining 2% are patients that would be in for greater than 4 weeks - but having 1

2 completed multiple episodes, have their notes pulled for future clinics, or have been transferred to the community in all cases, the notes would not be available for coding. Assessment 5 of the clerical support staff are now in place, and improving access to case notes, leaving the Coders free to code. The 2 Coders have been appointed, and their 2 year training programme has begun. Under-investment and lack of support for the Coding Department in the West is being addressed by direct support from management, and best practice being shared across sites. The West did not implement Coding support software East and Central have Medicode, which increases speed, accuracy and depth of Coding. Agency staff working weekends (due to lack of office space) have reduced the backlog first in the East, then Centre, and have recently begun in the West. As at 09/11/11, the Health Board was achieving 97% for the 12 months from Oct-10 to Sep-11, and 94% for the 12 months from Nov-10 to Oct-11. East and Central are achieving 4 and 6 weeks respectively, while West is failing the target, but is only just beginning to benefit from the additional investment. See Appendix 1 for further detail. The Coding Teams are implementing a joint action plan with a view to a standard approach to Coding across BCU. This includes a structured set of external audits to validate depth and quality of Coding. The restructuring and OCP process has stopped the appointment of the 3 Coding Auditors, and inevitable backfill. There is a need to increase the pace of change in the West. There is a need to address the shape of the backlog tail. Lack of Coding software in the West reduces the speed and accuracy of Coding this should be implemented as soon as possible. An initial estimate for the coding software is approximately 50k. Initial analysis of the backlog (once below 4 weeks)suggests that long term additional increase in Coding staff is not the answer, but process change within the organisation. 2

3 Further improvements in timeliness are likely to be of clinical benefit (in terms of data quality and engagement), rather than support additional revenue from English contracts or non-commissioned activity (NCA). By March 2012 it is anticipated that there will be a stable backlog of coding of approximately 4 weeks provided that remaining planned investmentis made in a timely manner. An analysis of the 192 September uncoded episodes for Wrexham, undertaken at the end of October identified only 14 that were currently available to code. Approximately half of the remainder were either still inpatients, or tracked to clinicians or secretaries. These would require a process change to improve the availability of notes while a patient was still receiving care. There were also 10 sets of notes current classed as missing. A significant amount of the backlog approximately 20% of the current load in the West is coded within Community and Mental Health and are not managed by Informatics. BENFITS OF REDUCED BACKLOG By March 2012 the coding backlog will be much improved over the existing performance and variation in backlog will have been reduced. It is important to quantify how reducing the backlog will benefit the organisation. The table below details scenarios for improved coding performance and potential costs and benefits of achieving more timely coding. Scenario Qualitative Benefit Financial Benefit Cost Comments 95% in 12 weeks (current target) 98% in 4 weeks (by March 2012) Negative lack of clinical engagement. Most of the previous month s information will be available for detailed analysis. CHKS data could be made available more quickly Data for SLR far more timely. More relevant and timely patient safety and mortality indicators Clinical engagement possible. Current WAG target achieved, finance figures available for cross border billing. As above. Service Line Reporting data accuracy and CPG engagement improved. Approximately 50k capital investment for Medicode software and approximately 5k recurring maintenance costs. No additional staffing over and above already committed by the organisation. Coding is more or less complete within 3 months at the moment how is this accurate but less timely being used currently and how will timely information be used by CPGs and corporate services to improve services? 3

4 98% in 3 weeks ( by August 2012) As above. Data available for submission to data warehouse, Welsh Government (PEDW), CHKS, and full in month analysis and clinical debate. As above Process change. This would require significant process change in the way in which case notes move around the hospital, and a Just In Time approach to their use for clinics. Cost: 3* Band 2 Clerks 1* Band 4 Coordinator All for 24 months = 213,162 How would CPGs use this how would we guarantee that this information is being used effectively? 4

5 Discussion More timely accurate coding is clearly a good thing. However, the issue of how the organisation would then use the information should be clarified before further investment is made in introducing the required process changes within CPGs. It is important to understand how will knowing what happened in the previous month within 15 working days of the end of the month really drive change? Basically that data is currently available anywhere between 5 and 12 weeks after the event for most specialties and will be available a month in arrears by March The challenge is who will do what with the information? We need to be clear whether this investment is about removing barriers for discussions or problems i.e. clinical confidence in the data or for real financial gain or is it a mix of both? Recommendations The following recommendations have been approved by the Informatics management team: The remaining (0.5) Clerical Support staff be appointed in the West urgently. The department should move ahead to appoint the Coding Auditors, and any subsequent vacancies, given the training lead in time for qualified Coders. A monthly update on coding completeness to be provided to CPGs and Finance colleagues for information. The Informatics Department should invest in Coding software for the West as a matter of urgency funding should be sought (Estimated at 50Kcapital but requires confirmation of costs through Procurement). If the above recommendations are supported the Clinical Coding Managers have confirmed that 98% coding at 4 weeks is an achievable and sustainable target. Should the process change to achieve 3 weeks be supported, then additional revenue investment would be required ( 213,162) for a maximum of a two year period. The improvement in coding backlog has been an excellent achievement over the past year but evidence shows that we have exhausted options for doing things better through providing more coding support. We now need to do better things e.g.review the structures of staff who code in the Community and Mental Health and modernisethe whole process which will involve changes in the way clinical staff deal with the records. Ultimately the coding process will be transformed through the introduction of Electronic Document Management System which will allow simultaneous direct access to patient information for clinicians, auditors, coders etc. 5

6 Appendix 1 BCUHB Coding Completeness Performance as at 25/10/11 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 West Not Coded Coded % Coded 97% 96% 95% 95% 96% 94% 93% 95% 94% 91% 89% 87% 82% 68% 91% Central Not Coded Coded % Coded 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 99% 98% 91% 67% 97% East Not Coded Coded % Coded 99% 99% 99% 99% 100% 99% 99% 100% 100% 99% 98% 98% 96% 57% 96% % Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% Total Coded 99% 98% 98% 98% 98% 98% 98% 98% 98% 97% 96% 94% 89% 65% 95% 12 month performance: 97% 94% In the previous 3 financial years, BCU achieved the 95% target, but only just. The current rolling 12 month performance is already well ahead of this for two sites, with a trajectory for all sites being 98%+ by the end of April