Working with national clinical audits to improve clinical documentation for coding - examples from Ireland.

Jacqui Curley ^a, Marie Glynn ^b, Helen Nolan ^c

Introduction
In Ireland, as with most countries, one of the main challenges in coding is the variation in the quality of clinical documentation and how to address this. This challenge impacts on the quality as well as the timeliness and efficiency of HIPE coding.

The Hospital In-Patient Enquiry (HIPE) collects activity data on admitted patients in public hospitals in Ireland. The Healthcare Pricing Office (HPO) manages this data set including the provision of training for HIPE coders along with data quality and audit functions. There are approximately 320 HIPE staff nationally including HIPE coders and Managers and there is a national HIPE portal data entry system developed in-house for data entry and reporting.

The HPO works closely with the National Office of Clinical Audit (NOCA) as HIPE data is utilised by a number of the audits managed by NOCA including the National Audit for Hospital Mortality (NAHM), Irish National Audit of Stroke (INAS), Irish Heart Attack Audit (IHAA), Irish National ICU Audit. Through this collaboration the HPO has identified areas where there is support and engagement for improvement of clinical documentation.

Methods
The engagement to improve clinical documentation through collaboration with NOCA and the vaarious audits includes the following methods:

• Audit co-ordinators- hospital level

For some audits such as INAS there is a NOCA audit contact in each hospital - this provides an opportunity for local HIPE teams to engage directly where there is a coding query or a documentation issue.

• Audit Managers - national level:

Each audit has an Audit Manager in NOCA and the HPO collaborates with Audit Managers where there may be a query on the HIPE data in relation to an audit finding or a data quality query. The HPO can review data and perform chart based audits where necessary and these may identify a documentation issue that can be addressed through the clinical audit.

• Education and Awareness - Local and national:

Where appropriate NOCA's audit reports raise any issues related to clinical documentation and the impact of the variation in on the coding of the data. NOCA audit staff have presented to HIPE coders at HPO training courses and provide information and expertise on dealing with documentation queries. HIPE staff inform the NOCA teams of the challenges they face on the ground.

Results
The HPO has performed a number of reviews related to NOCA audits where chart documentation has been identified as an issue for example

• documentation of STEMIs and NSTEMI's
• documentation of palliative care
• sequencing of diagnoses such as heart failure
• Variation across sites due to local instructions from clinicians to coding teams

Working with NOCA these issues are highlighted and local steps taken by the individual sites to address the issues identified.

These reviews have also identified a need for clinical teams and coding departments to communicate particularly around coding guidelines for sequencing, principal diagnosis and additional diagnoses definitions.

Conclusions
The collaboration with the various NOCA audits has brought clinical focus onto the importance of clinical documentation and the challenges faced by HIPE coders in abstracting information in a timely and accurate manner and in line with coding guidelines.


^a Head of HIPE & NPRS, Healthcare Pricing Office, Ireland, Ireland
^b Head of Clinical Coder Education, Healthcare Pricing Office, Ireland, Ireland
^c Interim Head of HIPE Clinical Coding, Healthcare Pricing Office, Ireland, Ireland

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