August 20, 2008
To: Conway Regional Patients, Visitors and Community Members
From: Jim Lambert, President & CEO
Re: Quality/Mortality Data Release from CMS
In an effort to keep you informed, I want to make sure that you are given background on an issue that has become public regarding some disappointing statistics. I want you to know the “story behind the numbers” so that you can better understand the situation. There was a Quality/Mortality Data Release by CMS (Center for Medicare and Medicaid Services) on August 20 on their public reporting website www.hospitalcompare.hhs.gov. There are a multitude of positive scores regarding our Core Measures however following are the disappointing ratings for mortality that have been reported about Conway Regional:
30 Day Mortality Rate – AMI (Heart Attack): No Different Than U.S. National Rate
30 Day Mortality – Heart Failure: Worse Than U.S. National Rate
30 Day Mortality – Pneumonia: Worse Than U.S. National Rate
I can tell you, with all certainty, that our patient care at Conway Regional is excellent and we have met and exceeded the state and national average on many of the Core Measures. I am disappointed that the numbers do not reflect that excellent care for heart failure and pneumonia that our team provides. The primary factor in our low scores has been determined to be our documentation and the effect that this had on our coding process. We have taken great strides over the last 12 months in correcting that problem. The Core Measures, which include this mortality data, are built around clinical best practices and we are focusing our efforts to determine how Conway Regional will meet and exceed the national averages in all we do. We are on the right track now in regards to the clinical documentation piece and our scores should be reflecting that soon, however; this CMS mortality data is over a year old and is only calculated annually and will not fully reflect these improvements.
We have been very proactive and forthright with local and state media and giving them the facts behind our data. Attached are some facts to help you understand this complex public reporting data and assist you in addressing any questions you may be asked in the community:
CMS Quality/Mortality Data - Key Points
• We take full responsibility for this issue and are actively reviewing all processes related to quality and patient care, in addition to clinical documentation, in an effort to improve our processes and ultimately our publically reported scores.
• This is old data. The data in this report was collected from July 2006 through June 2007. We learned that there was a clinical documentation issue in our billing data in June 2007. The data for this report was “already in the book” by the time we discovered the clinical documentation issue and unfortunately this report will not reflect the many steps taken to correct the issue.
• This is billing data and not reflective of the clinical care that was rendered to the patient. CMS never reviewed the actual patient charts – they are reporting only on the billing data.
• Every patient’s chart has been reviewed by a team of local physicians and it was found that the care provided was good, sound, clinically appropriate, high quality health care.
• After intense review by our physicians and by AFMC (Arkansas Foundation for Medical Care – an organization dedicated to improving quality in all Arkansas hospitals) it was determined that the results reported by CMS were directly connected to our clinical documentation and how this clinical documentation translated into language that the coders could use in choosing the codes used for billing.
• In most cases our team used the appropriate clinical documentation to reflect what was happening with the care of the patients. Unfortunately, this documentation was not in line with the language required in the coding rules. As a result the billing codes did not accurately reflect the severity of the patient’s condition and the quality of care delivered.
• We have addressed the issue head on. We’ve invested significant resources in a new system and manpower to adjust our clinical documentation process in order to help the physicians and other care givers to understand how to phrase their documentation in a way that is consistent with the Medicare coding rules.
• We realized last year, when this type of data was first released, that investing in a clinical documentation system earlier on would have made a significant impact on our billing data, and ultimately this type of reporting. However, we are at the same time very proud that over the last several years we’ve invested significantly in other areas of quality and patient safety such as purchasing new patient beds, a state-of-the-art medication dispensing system, the Picture Archival Communications System (PACS) and expanding our infant security system.
• Next year’s report may not reflect all the changes we’ve worked so earnestly to incorporate these last 12 months because those new processes went into full function in February of this year and that will affect a little less than half the reporting time period for the 2009 report. However, we feel that the changes we’ve made will be reflected in upcoming reports by CMS.
• Our primary concern has been, and will continue to be, providing high quality compassionate care for the patients we serve.
For additional information about our quality data click here.