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Improving Workflow Process for Discharge Processing Read the entire document. Use Table #2 which shows the steps in the redesign of the workflow to create a workflow diagram. Standard symbols must be used and all steps must be included. Background Information The transition to an electronic health record system EHR has changed many of the processes for the hospitals including the processing of discharges. The Chief Financial Officer (CFO] expects the change to electronic records to reduce the DNFB (Discharged Not Final Billed) backlog to drop 70% and result in improvement in the revenue cycle. The goals is to drop the bill within three days of discharge. Coding performance is a focus in this process. The HIM department has identified problems in the process include the following: Discharge summaries are to be dictated within two days of discharge, but there is a lag in receiving the physician's discharge summaries causing the transcriptionist to scurry to complete in time. The process of coding and dealing with problems is not efficient and requires a redesign for process improvement. As the Coding Manager, you will be working with the HIM Director and other to re-engineer the current workflow. Introduction The Chief Financial Officer (CFO) has a lofty goal of decreasing Discharged Not Final Billed (DNFB) processing to decrease the backlog by almost 70% to comply with final billing completed within three days of patient discharge. The switch from paper-based records to Electronic Health Records (EHR) can make such a change possible because bottlenecks and delays from deficiencies are minimized through the efficiencies made possible by the people, the process, and the technology. Challenges that threaten completion within the three-day window, however, remain. A root cause for delay in the process is the same as with paper; HIM team members have identified it as tardy discharge summaries, responsibility of the attending physician with requested completion guideline of 48 hours, but currently, an absolute deadline of 30 days to comply with regulatory standards. Using People and Technology to Reengineer the Process Brainstorming with a focus group comprised of a multidisciplinary team involving the Coding Manager the EHR Process Manager, the Chief of Staff, and the IT Department is conducted to determine factors that can facilitate the process. Following best practices set by the Joint Commission, the Discharge Summary must contain the following essential elements (Kind & Smith, n. d.): 1. The reason for hospitalization. 2. Significant findings. 3. Procedures and treatment provided. 4. Patient's discharge condition, 5. Patient and family instructions (as appropriate). 6. Attending physician's signature.Requirements for the process were assessed, and some changes in roles, technology, and policy were made to support the redesign of the workflow. Attention to the data flow to support the work was a primary concern in re-engineering the discharge processing within the HIM department. Testing of the redesign is necessary before implementation and education of the staff is an obvious function in acceptance of the change and success of the endeavor. Table 1: Proposed Solutions for Process Redesign Issue Solution Responsible Comment Party Discharge Summary Policy and Clinical and Defined discharge summary contents procedure Administrative contents are needed to assure that Leadership documentation is standardized and provides the information necessary for the coding process. Discharge Summary A template for IT Department By creating a form that contains the Deficiency or Absent information with essential elements guarantees Field entries that documentation supports coding require process and mitigating the risk of completion before missing elements. Proceeding to next step; Consolidation of Use of queue EHR Process The use of queue functions will charts to process Manager mitigate the chance of a chart "getting lost in the shuffle" and will assure timeliness in the process. Deficiencies are Policy changes. Chief of Staff The 30-day window is no longer corrected within two appropriate for discharge summary days completion with electronic records. Coding completion window standard is now three days. Improvement with Education Clinical Those physicians who are adherence to Document responsible for deficient or Discharge Improvement delinquent discharge charting Documentation (CDI)Team requirements must be educated to Policy prevent further issues. Quality Assurance Deficiencies are Clinical Data will be collected for analysis to corrected in a Document monitor and control the process. timely fashion. Improvement (CDI) Team Coding efficiency Only complete HIM staffing Coding efficiency is supported by documentation involved in complete and accurate reaches coders process documentation, No discharge processing charts should be in the coder's queue until it has been deemed complete and ready to code.Process Redesign The old process was burdened not only with paper, but with delays, time and labor intensive paper shuffling, and dependence upon the physicians to correct deficiencies. The new workflow process using electronic technology eliminates paper, but delays including physician documentation of the discharge summary persist. Mitigating these factors can be accomplished in the redesign so that coders will not be burdened with delays from incomplete documentation or time lost in chart review. Quality assurance is built-in to the process to monitor and control the correction arm of the workflow utilizing CDI. It is expected that educating physicians will reduce the quantity of tardy charts and improve the quality of the process and that the support of the Chief of Staff and policy updates will serve to support these efforts. Finally, the EHR Process Manager will work with the IT staff for a continuous quality improvement (CQI)in the process. The process redesign was developed to allow the use of technology to improve the efficiency and accuracy of the coding process. HIM department roles were redefined to assure that appropriate skill levels were in place to accommodate the tasks. The Discharge Analyst role was expanded as were CDI team responsibilities. The decline in DNFB is projected to be met or exceeded the CFO's goal, It is expected that coding time will achieve greater efficiency and accuracy because time traps and bottlenecks reduce waste time by allowing only complete documentation to reach the coders. Physician discharge summary notifications are electronically sent with persistent reminders at intervals until the task is completed. The latter serves to "train" the physicians to adhere to needed documentation. The CDI Team will be approaching physicians to educate them on the importance of the timely completion of the discharge summary and technology that can assist in the process. As a plus for operational expenses, a reduction in coding FTE may be eventually possible due to greater efficiency. The narrative description for the workflow redesign is contained in Table 2 with the diagram depicting the new workflow follows. Table 2: Discharge Processing Functional Description Step Process Task Description Next Function/Responsibility Type Step Start 1. Start/trigger Patient Has been discharged 2 Registration (ADT) Process 2. Pull Daily Discharge Analyst reviews 3 Discharge Analyst Discharge daily discharge report Report summary Process 3. Perform Discharge analyst review 4 Discharge Analyst Analysis chart for all required components. Decision 4. (Is discharge Yes-If Data Analyst 5 Discharge Analyst summary determines that chart is present and) complete, go to Step 5 complete? No- If Discharge Analyst determines that the chart is missing discharge summary or needs physician correction, go to Step 6 6Process 5. Send report Discharge Analyst marks 21 Discharge Analyst to coder chart complete in EHR and chart appears in coder queue Process 6. Flag Chart Discharge Analyst marks Discharge Analyst deficiency Process 7. Place Hold in Discharge Analyst marks 7.1 Discharge Analyst Chart status as "Hold" for chart in and EHR. 7.2 Process 7.1 Notify CDI As a function of the hold 8 EHR being placed on chart, the notification/tracking Clinical Document Improvement team receives electronic notification of the chart(s) on hold . Process 7.2 Notify MD of As a function of the hold 10 EHR Hold being placed on chart, the notification/tracking attending physician receives an electronic notification of chart (s) on hold. Decision 8. (Has chart The CDI team member Clinical documentation been) reviews queue to determine Yes, team Corrected? if chart has been go to corrected/completed shown 9 with completion date in EHR If yes, complete Step 9 If no, repeat Step number 7.2. This loop continues a cycle until discharge deficiency is corrected. The standard is two days, the If No maximum allowable is up to go 3 days. back to 17.2 Documentation 9. Document CDI documents physician EHR CDI team created and MD performance is correcting EHR Process Manager Performance and completing deficiencies to measure process improvement. Process 10. MD Corrects MD corrects flagged EHR deficiencies and chart is Notification/tracking returned to discharge queue and is reprocessed at Step 3.Process 11. Code chart Coder selects next 12 Coder completed chart from queue to code End 12. Discharge Completed charts are made EHR Billing department Processing is available to final billing completed process. Reference Kind, A., & Smith, M. (n.d.). Documentation of Mandated Discharge Summary Components in Transitions from Acute to Subacute Care. Retrieved from https://www.ahrq.gov/downloads/pub/advances2/vol2/Advances-Kind_31.pdf