HIM 690 Module 7 Recommendations Short Paper Example

From Findings to Fixes: Recommendations and an Implementation Plan From the Cimarron Heights Flag Accuracy Capstone

[Student Name]

Southern New Hampshire University

HIM 690: Health Information Management Capstone

Module Seven Short Paper

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

From Findings to Fixes: Recommendations and an Implementation Plan From the Cimarron Heights Flag Accuracy Capstone

A capstone's results matter only if something changes because of them. The Cimarron Heights capstone produced three findings that point to action: pressure wound flags were wrong in about two of five records, mostly calling hospital-acquired wounds pre-existing; charts lacking a first-day skin and Braden check carried more than three times the adjusted odds of a wrong flag; and interviews showed coders defaulting to yes because they had no way to ask nurses and could not easily see nursing skin findings. This paper turns those findings into five recommendations and a plan to carry them out.

Recommendation 1: Require the First-Day Check

The nursing admission note should not be signable until the structured skin inspection and Braden risk assessment are complete, as already happens on the one unit whose template requires it, where documentation reached 92% and disagreement was lowest. Braden scoring (Bergstrom et al., 1987) is already routine on every unit, so the change is to template logic, not to clinical practice. Owner: chief nursing officer, with the clinical informatics team. Cost: about 40 hours of build and testing time. Measure: share of admissions with a completed check within 24 hours, from 70% to at least 90% within three months.

Recommendation 2: Give Coders a Way to Ask Nurses

The query process should be extended so that coders can send a structured question about skin condition at admission to the admitting nurse or unit nurse manager, with a two-day response expectation. Owner: HIM director with the nurse managers. Cost: minor configuration of the existing query tool and a one-hour training session for each group. Measure: number of nurse queries sent and answered, and the share of wound flags supported by a documented nursing finding.

Recommendation 3: Replace the Yes Default

Coding policy should state that when no admission documentation supports a condition being present on arrival and no query has resolved it, the flag must reflect the documentation, which usually means a value of documentation insufficient or no rather than yes. Coders described choosing yes to avoid implying the hospital caused harm; the policy makes clear that accuracy, not reassurance, is the standard. Since present-on-admission values shape reported safety rates (Bahl et al., 2008), this policy will likely raise the hospital's reported pressure wound rate in the short term, and leaders must be told that in advance. Owner: coding manager, with compliance review. Cost: policy revision and training. Measure: share of wound flags with documented support at audit.

Recommendation 4: Bring the Skin Findings to the Coder

The coding workspace should display the first-day nursing skin assessment alongside physician notes, so coders do not need to search a separate flowsheet. Owner: HIM director with clinical informatics. Cost: an estimated 60 hours of build time. Measure: coder-reported time to locate skin findings and the share of wound flags consistent with first-day documentation.

Recommendation 5: Re-Audit Every Quarter

The abstraction tool and rules developed for the capstone should become a quarterly audit of 40 pressure wound records and 20 records for each of the other complications, using the same double-abstraction check. Kahn et al. (2016) describe data quality assessment as an ongoing practice of verification against rules and validation against references, and a repeated audit with the same method is what will show whether the changes worked. Owner: data integrity manager. Cost: about 50 hours of coder time per quarter. Measure: pressure wound flag agreement, from 61% toward at least 85% within a year.

Implementation Sequence

The order matters. Kotter (1995) found that change efforts lose momentum without short-term wins that people can see and that leaders should plan for those wins rather than hope for them. The fastest visible gain is the coding workspace view and the nurse query path, which coders asked for and which can be live within six weeks. The template requirement follows in month two, after nursing leaders review the one unit where it already works. The policy on defaults is issued in month three, together with a message to the quality committee explaining why the reported wound rate may rise. The first quarterly re-audit runs in month four, and its results are shared with the coders and nurses who made the changes.

Table 1. Implementation Timeline

Note. Costs are mostly staff time within existing budgets.

What Was Not Recommended

Two tempting options were left out. The first was retraining every inpatient coder on present-on-admission rules. The model found no difference by coder experience, and interviews showed that coders knew the rules but lacked the information and the query path to apply them; training alone would have addressed a problem the evidence did not show. The second was asking wound care nurses to review every pressure wound flag before billing. It would likely improve accuracy, but it would add about 110 reviews a year to a team of three, and it patches the claim instead of fixing the missing first-day note that leaves coders guessing. If the re-audit shows that the five recommendations are not enough, a targeted review of facility admissions with wounds could be added later.

Risks

The main risk is that a rising reported wound rate is read as worse care rather than better data. Leaders will be briefed before the policy change, and the quality committee will see accuracy and rate side by side. A second risk is alert fatigue if the template requirement is seen as one more hard stop; nurses from the unit that already uses it will be asked to describe how it fits their workflow.

Conclusion

Each recommendation answers a finding: the check answers the documentation gap, the query path and coding view answer the coders' blind spot, the policy answers the default and the re-audit answers the question of whether any of it worked. The plan asks for little money and a great deal of coordination, which is the kind of change health information management is positioned to lead.

References

Bahl, V., Thompson, M. A., Kau, T.-Y., Hu, H. M., & Campbell, D. A. (2008). Do the AHRQ patient safety indicators flag conditions that are present at the time of hospital admission? Medical Care, 46(5), 516-522. https://doi.org/10.1097/MLR.0b013e31815f537f

Bergstrom, N., Braden, B. J., Laguzza, A., & Holman, V. (1987). The Braden Scale for predicting pressure sore risk. Nursing Research, 36(4), 205-210. https://doi.org/10.1097/00006199-198707000-00002

Kahn, M. G., Callahan, T. J., Barnard, J., Bauck, A. E., Brown, J., Davidson, B. N., Estiri, H., Goerg, C., Holve, E., Johnson, S. G., Liaw, S.-T., Hamilton-Lopez, M., Meeker, D., Ong, T. C., Ryan, P., Shang, N., Weiskopf, N. G., Weng, C., Zozus, M. N., & Schilling, L. (2016). A harmonized data quality assessment terminology and framework for the secondary use of electronic health record data. eGEMs, 4(1), Article 1244. https://doi.org/10.13063/2327-9214.1244

Kotter, J. P. (1995). Leading change: Why transformation efforts fail. Harvard Business Review, 73(2), 59-67.