Clinical Coding team in KGH translate medical terminology in notes into codes which then gives us data on the care we have provided and is also used by commissioners to result in income.
The transformation team have led a Clinical Coding programme alongside the coding team and sponsored by our CDiO to improve the accuracy of our clinical coding (started late Jan 2019), the coding department serve every inpatient area of the Trust and are vitally important. We are on a journey to take them from ’lost and unloved’ to our ‘superheroes’ of the organisation
The clinical coding team were, prior to January 2019, the unsung heroes of our Trust (KGH). It was recognised they were a team integral for the smooth running of our Trust and yet, we did not prioritise them. The coding team were left to their own devices with little support and KGH realised this needed to change. Without sufficient support and investment, how could we expect our clinical coding to be accurate and of high quality? Therefore, the transformation team were engaged with who initially led a review of the service to highlight if there were Indeed opportunities to improve.
The result of this review demonstrated an opportunity and the programme then had the following goals:
- To find opportunities to support clinicians and coders to more accurately code so KGH’s activity records reflect reality and thus results in the trust being paid the right amount
- Depth of coding uplift from 4.6 to 5.6 (KGH were pulled up in GIRFT reviews and against counterparts for having a poor depth of coding)
- Depth of coding increase should result in an overall uplift in income for the trust. Target 4% of Income
- Furthermore, increased coding accuracy will ensure our services are set up to support our patient case mix enabling us to provide the right care for our patients
- We need a sustainable approach which enables coding errors and opportunities to be identified in the longer term therefore ensuring our recorded activity continues to reflect reality
- Alongside this, we need to build a common understanding amongst KGH staff about coding and the roles people play in it thus promoting a collaborative approach to improving coding trust-wide.
KGH pride themselves in their vision ‘to provide safe high quality care to our communities’ - if we do not accurately record the care we are providing, we are not:
- Getting the right reimbursement for the services we provide which can be invested in care
- Knowledgeable on the demands placed on our Trust including the type of patients we see which means we might not invest in the services most in need
This programme had a multi-pronged approach to ensure all views were heard and involved in shaping the direction of the project. Staff know best where opportunities are to improve so they were integral to programme success (both clinical and coders). We also learnt from other Trusts to understand best practice.
This programme was (and continues to be) successful because it listens to staff, learns from other Trusts, has support from across KGH and the programme has robust structure to ensure the programme delivers and any risks were escalated and mitigated smoothly. See the value section for some quantitative and qualitative data on Improvements.
As a result of the following, this is what has led to the improvements (only examples below due to word limit):
- Demand and capacity analysis completed showed against industry standard, we did not have sufficient staff to meet capacity. Therefore, we have invested in our structure and grown the team. This has meant coders are no longer rushing the coding to get through the quantity but can now focus on the quality
- Increasing support for our coders: We have invested in a trainer position which is critical to ensure our trainee heavy team get the support they need. This role will also be responsible for trust-wide engagement and training especially with clinicians. We have invested in an auditor to give all our coding staff regular feedback on their coding but also help us provide assurance of our coding quality to the Trust
- We have secured an estates solution to ensure the coding staff have a suitable environment to work in and are no longer in neglected accommodation
- We are changing the culture so the coders have now a two team mentality - a home team (coding) and an away team (their speciality) - they spend increasing time on the wards with their away team, working with them to improve the coding and ward understanding of effective coding
- Increased clinical awareness and engagement with coding by creating an awareness strategy that included many engagement methods from master class training, to videos in our lunch area to formal training to communication campaigns through screensavers. This complements the 1:1 coder support areas are increasingly getting
- Reviewed performance management and KPI reporting of coding - mapped KPIs from team level (covering quality, delivery and cost) to Exec level. This now gives the assurances at Exec level of the coding quality and quantity as well as helping the coding team to own their performance and help them to continuously improve.
As part of the initial review completed by the transformation team, we approached other NHS trusts to learn from them. We learnt about what worked well and less well so we could incorporate these lessons learnt into our programme. Now the programme is seeing great benefits, we are sharing our insight with these Trusts to:
- Say thank you for their support and
- Help them to further improve
Within the programme themselves, the coding team are increasing their interaction with clinicians to share best practice on areas for them to improve their medical records quality thus helping accurate coding. The clinical engagement and awareness strategy includes a variety of methods to ensure coding (and by extension patient record capture) best practice is shared regularly to all staff-this includes (but is not limited to) videos, training, induction material, screensavers, newsletters the list could go on.
Within the team, the programme has set up a team-owned huddle for the coding department. The coding department identified there was an opportunity to improve communication, focus on performance and continuous improvement which the huddle promotes. They are also determined the cultural changes and improvements they are making will not fall victim to the traditional pattern of “grass growing back” by introducing a huddle this will not only promote sustainment of the improvements they have made but also focus on adopting a continuous improvement culture. As part of this huddle, the team are encouraged to talk on a twice weekly basis about best practice amongst the team so they can improve incrementally amongst themselves.
The programme’s approach has been heralded as best practice and is being adapted for other programmes. In particular, its focus on:
- Engaging with staff and the variety of tactics in doing this
- Communication (again varieties of) but also the spread
- Providing assurance to the rest of the organisation on the programme delivery
- Considering benefits from a patient, staff and Trust perspective
- Monitoring of benefits throughout the programme
- Governance and risk escalation process
Evidence of improvement:
- Depth of coding has improved. We now monitor this in SPC format and prior to project, upper and lower control limits were 4.5 and 5.3. Limits have improved as a result of project: they are now 5.4 and 6.1. This shows our patient information is richer and is more accurately reflecting what our patients comorbidities are. Now the HRG categories our patients are in, more accurately maps to their expected length of stay
- We have calculated the financial impact as 4% of our income to be due to coding improvement (targeted 3% showing over delivery)
- Coding auditing results are consistently passing national benchmarks (and we are now doing more of these than ever before thus giving KGH the assurance on coding quality but also coders are getting the feedback and support they need and want to improve)
- Coders feel happier, more supported and hopeful for the future as shown with quotes from 1:1s we have had with them (which can be made anonymous and provided)
- Clinicians feel more integrated with coding and aware of their impact
- Most important of all: patients! Although they may not feel how this has impacted them when they visit, this project has most certainly positively impacted them and will continue to do so. We are more confident in the information we have recorded about patient stay and treatment - we therefore are able to invest and support the services which need it most (and which are patients do tool). With correct financial reimbursement we are able to invest in the services they need to provide.
As an aside, this programme has also improved flow from ward to coding as we have reviewed and enhanced the flow and timeliness of medical records.
This programme had a robust communication and engagement strategy with many different stakeholder groups:
- A bottom up approach: Coders themselves were at the heart of the change as they understand the challenges they face on a daily basis and critical areas to improve. The programme engaged with them through workshops, one: one sessions, questionnaires and opportunity boxes to make sure they were able to drive the programme. We also communicated regularly with them through newsletters, meetings and drop in sessions so they were always up to speed. Our Exec team hosted coding breakfasts with the coding team to ensure they could hear first-hand from the coders but also demonstrate their support for the programme and recognise all of the hard work from the coding team. Assurances were given to the team on how this programme was aiming to help the coding team and work with them in order to do this. Coding team are one of the main groups impacted by the change but our engagement approach ensured they felt like the owned the changes which therefore helped them through the change period
- Supported by leadership from the top: Exec team showed their support for the programme through aforementioned coding breakfasts and also speaking publically about coding and the importance of it across the Trust. The programme reported to a Trust Board Committee which showed KGH’s priority for the programme and also helped the escalation of any programme risks.
- Clinical staff: Clinical staff are a key part of the coding process - the coders can only code the information provided by clinicians. They were engaged with through Clinical Leads meeting and through representatives at the Committee. We also had a Clinical Champion who sat on our Programme Steering Group who was the Clinical voice in the project. Each speciality was engaged with through their coders. Existing groups/ meetings were utilised where possible to avoid disruption to patient care.
- Trust-wide communication: We linked with our internal communications team to ensure the programme was communicated regularly across the Trust so all areas knew the programme was going ahead
- Other trusts: as said previously, we utilised our broader NHS network to see what best practice we could learn from.
This programme will continue as we to endeavour to continuously improve in order for our coding to be what we internally would say as ‘gold superhero standard’.