title: Surgical Precision in Clinical Documentation Connects Patient Safety, Quality of Care, and Reimbursement.
abstract: Emphasis on quality of care has become a major focus for healthcare providers and institutions. The Centers for Medicare and Medicaid Services has multiple quality-of-care performance programs and initiatives aimed at providing transparency to the public, which provide the ability to directly compare services provided by hospitals and individual physicians. These quality-of-care programs highlight the transition to pay for performance, rewarding physicians and hospitals for high quality of care. To improve the use of pay for performance and analyze quality-of-care outcome measures, the Division of Plastic Surgery at Scott & White Memorial Hospital participated in an inpatient clinical documentation accuracy project (CDAP). Performance and improvement on metrics such as case mix index, severity of illness, risk of mortality, and geometric mean length of stay were assessed after implementation. After implementation of the CDAP, the division of plastic surgery showed increases in case mix index, calculated severity of illness, and calculated risk of mortality and a decrease in length of stay. For academic plastic surgeons, quality of care demands precise documentation of each patient. The CDAP provides one avenue to hone clinical documentation and performance on quality measures.
authors.affiliation: Division of Plastic Surgery in the Department of Surgery at Scott & White Healthcare/Texas A&M Health Science Center College of Medicine in Temple, TX.
authors.forename: Benjamin J
authors.initials: BJ
authors.lastname: Kittinger
authors.affiliation: Department of Medicine at Community Medical Center-Barnabas Health in Toms River, NJ.
authors.forename: Anthony
authors.initials: A
authors.lastname: Matejicka
authors.affiliation: Division of Plastic and Reconstructive Surgery at Mayo Clinic Hospital in Phoenix, AZ.
authors.forename: Raman C
authors.initials: RC
authors.lastname: Mahabir
mesh_terms: D014487:Centers for Medicare and Medicaid Services, U.S.; D015897:Comorbidity; D003953:Diagnosis-Related Groups; D004282:Documentation / Q000592:standards*; D017052:Hospital Mortality; D006761:Hospitals; D006801:Humans; D061214:Patient Safety; D011787:Quality of Health Care; D012052:Reimbursement, Incentive; D013518:Surgery, Plastic; D014481:United States
keywords: case mix index; coding; comorbid conditions; diagnosis-related group; documentation