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Excerpt

HIM Evidence-based Operations


Management: A Case Study
By Susan H. Fenton, PhD, RHIA, CPHI, FAHIMA, and Diann H. Smith, MS, RHIA, CHP, FAHIMA

Editor’s Note: This article was first published as part of the Fall 2019 issue of Perspectives in Health Information Management.

Abstract than any other provider. The system’s primary service area con-
This is a case study of the evidence-based management practic- sists of 16 counties, home to more than 7 million people.
es of a centralized health information management (HIM) depart- The healthcare delivery system was formed in 1997 with the
ment in a large integrated healthcare delivery system. The case assets of two large existing hospital systems. Later that year,
study used interviews and focus groups, as well as de-identified another hospital in the area joined the system.
dashboards, to explore the impact of reporting on the organi- Currently, the system has 27 hospital locations including 18
zation. The dashboards and key performance indicators (KPIs) acute-care hospital locations, five short-stay hospitals, three
were initially developed in 2012 and have continued to evolve rehabilitation hospitals and one transitional care hospital, all
since that time. The themes that resulted include: owned, operated, joint-ventured or affiliated with the system. It
1. Evidence-based management is integral to the culture of the has more than 4,000 licensed beds, employs more than 25,000
organization; people, and counts more than 6,200 physicians with active staff
2. Communicating regularly via dashboards and KPIs is key to privileges at its hospitals.
transmitting the value of HIM to the entire organization; and To our knowledge, this is the first case study exploring the use
3. Staff not only report the required measures for the dash- of dashboards and key performance indicators (KPIs), or the ev-
board, they take pride in it and often develop methods for idence-based management, of an HIM department. The authors
tracking their individual performance. believed this study was needed in order to demonstrate how
data can be used effectively and, hopefully, to suggest additional
The most evidence supporting HIM operations management areas for HIM operations data analytics.
is related to coding and clinical documentation improvement, This case study is important because it begins to build the
though even in those areas, national benchmarks are missing. foundation for evidence-based HIM operations management.
It is important for HIM to develop national and regional bench- Hopefully, this case study will also be utilized by HIM educational
marks to assist professionals in managing operations effectively programs.
and communicating their value to the healthcare industry.
Literature Review
Introduction The HIM profession has approached data management from
As a profession, HIM has been actively engaged in data man- many different perspectives, yet, publications related to evi-
agement since at least 1998.1 The last two decades have seen dence-based HIM operations management are difficult to find.
continued growth and use of data in healthcare. However, even Both PubMed and the American Health Information Manage-
today, the use of data to manage health information operations ment Association (AHIMA) HIM Library were searched. There
still deserves investigation. This case study was undertaken to are some, most often related to patient record coding and clini-
explore how the centralized health information management de- cal documentation improvement. 2,3 Unfortunately, this foci does
partment of a large integrated healthcare delivery system uses not encompass the entire range of HIM operations, leaving out
data to manage its operations. scanning and release of information, at a minimum. Other ar-
This integrated healthcare delivery system is a faith-based, ticles are focused on more broad-based analytics, applicable to
nonprofit system that cares for more patients in North Texas the delivery of healthcare, rather than the management of HIM

32 / Journal of AHIMA March 20


operations. 4, 5 While valuable, this does not assist HIM profes- clinical documentation improvement, data integrity, release of
sionals in managing their day-to-day operations. information, operations and regulatory compliance. Transcripts
Since approximately 2014, HIM’s professional association, AHI- were made of all sessions and grounded theory used as the anal-
MA, focused on information governance, performing studies and ysis method. A total of 50 persons took part in the focus groups,
creating many resources for healthcare organizations to imple- with six persons interviewed individually.
ment information governance. In 2017, Houser and colleagues
discussed the need for information governance related to sup- Discussion
port for analytics.6 This article reviewed several models that This case study explores the evidence-based HIM manage-
can be used when managing the information needed for man- ment of a centralized HIM department. For clarity, this case
agement, but never addressed the actual use of the data and study will focus on the reporting from each department to the
information for operations management. Likewise, the practice VP of HIMS and CDI, as well as to senior level executives at
brief for data analytics reporting provides guidance regarding the system level and executives at the entity level across the
the reporting lifecycle, reporting methods, and tools for report- healthcare organization. As with all case studies, one of the
ing; however, no actual example is provided.7 limitations is the examination of a single organization. Other
The lack of a comprehensive review of evidence-based op- HIM departments in other healthcare delivery organizations
erations management in case study or other form reveals a are expected to have different needs for their reports and/or
gap in the HIM literature. It is expected that the following case dashboards so these results cannot be generalized. Addition-
study is only a starting point for evidence-based HIM opera- ally, the subjective nature of the case study method may influ-
tions management. ence the case study, it can be difficult to replicate, and case
studies are time consuming.
Methods The HIM organization is centralized and complex, as might be
This case study is a joint project between a graduate program expected when managing HIM operations for 19 hospitals and
in health informatics and the large integrated healthcare deliv- related organizations. The organizational structure is found in
ery system. It was approved by the university Committee for Figure 1, available in the full version of this article published
the Protection on perspectives.
of Human Sub- ahima.org.
jects, approval
number HSC-
“AHIMA is the logical organization to The initial organi-
zational structure
SBMI-18-0567. lead the effort to collect HIM operations was established in
The meth-
ods chosen for management data that their members 2012 after a two-day
rapid design ses-
conducting the
analysis of the
can use for analytics and evidence sion that involved
all HIM directors
health deliv- to support operations. AHIMA could and managers; rep-
ery system’s
evidence-based become a source of benchmarks and a resentatives from
Human Resources
HIM operations
were inter-
resource for the healthcare industry.” and Information
Technology (IT).
views and focus Over time the orga-
groups over a two-day period. All interviewees and focus nizational structure evolved as responsibilities under the VP’s
group participants signed informed consents related to their leadership were added. Key objectives of the rapid design ses-
participation in the case study. The questions included a de- sion were to design and build the future state of the enterprise
scription of the Key Performance Indicators (KPIs) used, how HIM, identify best practices, create performance specifications,
they are selected and calculated, as well as how the data is and develop methods of communication. It was crucial to the or-
collected for each KPI. They were also asked about the evo- ganization to design a unified system approach to streamline op-
lution of the KPI reporting, and what they liked best or least erations and achieve excellence with the long-term expectation
about using and reporting KPIs. The IRB-approved focus of benchmarking operations. Consistent quality and timeliness
group and interview questions can be found in Appendix A, of data reporting across the enterprise with a focus on develop-
available in the full version of this article published on per- ment of leading-edge use of tools and enablers to consistently
spectives.ahima.org. support a leveraged enterprise HIM model was a key initiative.
The interviews were held with the Vice President of Health In- From the beginning the organization developed standardized key
formation Management Services (HIMS) and Clinical Documen- performance indicators “KPI” to be included in a reporting ma-
tation improvement (CDI), the direct supervisor, and the direct trix for each functional area. Performance baselines were estab-
reports to this position. Focus groups were held with coding, lished for post-implementation comparisons.

Journal of AHIMA March 20/ 33


The use of dashboards and KPIs for the HIM operations overall health of the organization.
have been in development over a period of five years. Staff 3. Setting and achieving goals instills pride in doing a job well
who worked in other healthcare organizations or those who across the HIM and CDI personnel. The staff not only report
worked at the health delivery system prior to the central- the required measures for the dashboard. More than one
ization of HIM services experienced a period of adjustment person reported that they have created their own individual
related to the extensive reporting, as well as the sharing of dashboards to track their individual performance.
the data. They reported initially feeling that the dashboard
reporting was going to be used as a “gotcha.” However, they As reported by the healthcare organization employees, an es-
discovered that reporting the data allowed them to identify sential component of a useful dashboard is benchmarks. Howev-
opportunities for improvement, as well as providing evidence er, as seen in Figure 2, approximately 62 percent of the HIM oper-
to celebrate achievements. It is important to note that not all ational measures used by this data-driven organization have no
goals are achieved. This is consistent with the practice of set- comparable industry-wide benchmarks. This lack of comparable
ting “stretch” goals. It must also be noted that the processes benchmarks was the topic of a recent JAHIMA article focused
and dashboard reviewed for this case study is not static. It on coding accuracy.8 It is reasonable to suggest that this lack of
has evolved and continues to evolve. comparable industry-wide benchmarks applies to a majority of
Data is gathered in a variety of ways from each staff member. HIM operations.
Examples include turnaround times for different types of re- Careful attention to Figure 2 reveals multiple measures where
quests for patient records; physician documentation compliance the organization standard is much stricter than the industry
by documentation type; data integrity as demonstrated by dupli- standard or there is an organization standard without an in-
cate accounts; scanning records management; coding productiv- dustry standard. For example, the release of information stan-
ity and denials; and a financial analysis of HIM operations. The dards for continued care request turnaround time (TAT) organi-

The last two decades have seen continued


growth and use of data in healthcare. However,
even today, the use of data to manage health
information operations still deserves investigation.
summary HIM dashboard is seen in Figure 2, while Figure 3 is zation standard is 7 days, against the Texas requirement of 15
the CDI dashboard. Figure 2 and Figure 3 are available in the days. The organizational goal for stat requests turnaround time
full version of this article published on perspectives.ahima.org. is 30 minutes with no industry standard, with a Year-To-Date
In order to preserve confidentiality for the organization, all data measure of 29 minutes. Similarly, the organization’s standard
in the dashboards is synthetic. The structure of the dashboards for medical record delinquency rate is 25% as opposed to the
is accurate. Joint Commission standard of 50%, with a reported Year-To-
In addition to providing an overall view of the measures for date rate of 2.1%. Both management and staff report use of the
the integrated healthcare delivery system, each hospital or dashboard and KPIs has resulted in an overall lowering of the
separate organizational unit receives a dashboard detailing targets over time demonstrating performance improvement.
their performance for all of the measures. For example, the Using a dashboard over a long period of time does not guar-
integrated health delivery system may be compliant with the antee problem-free management. During the interviews and
standard of 95 percent Completion of History & Physical Up- focus groups it was noted that the reporting for Release of
date within 24 hours for a given measurement period, while Information had recently encountered issues. Over a period
one or more of the hospitals or organizational units may not of several months, the staff reported that they believed the
be in compliance with the standard. dashboard numbers for a specific type of release request
Themes emerging from the interviews and focus groups are: were incorrect. They contended that the numbers on the re-
1. 
The focus on evidence-based management is pervasive port were not consistent with what they were witnessing in
across and throughout the organization. Most, if not all, or- their day-to-day operations. These reports prompted further
ganizational units have dashboards they utilize to help them investigation into the dashboard data that was automatical-
manage their areas using KPIs. ly extracted from the electronic health record (EHR). It was
2. Communicating regularly via dashboards and KPIs not only eventually determined that a recent upgrade to the EHR had
enables more effective management, it ensures senior man- altered the reporting related to the release requests. The no-
agement understands the impact of HIM operations on the table takeaway from this anecdote is that the front-line staff

34 / Journal of AHIMA March 20


receive and pay attention to the dashboard. Further, they feel What was especially noted was a lack of industry-wide bench-
empowered to report inconsistencies and discrepancies they marks that would be useful for HIM operations management.
discover in the data reported on the dashboard. This deficiency should be concerning for the HIM profession as
Utilization of the dashboard over time can also assist the HIM data becomes ever more ubiquitous and important in all aspects
department with compliance and external audits. In this organi- of healthcare delivery.
zation, the dashboard data reported for the transcription section AHIMA is the logical organization to lead the effort to collect
was required to undergo an external audit. For those not familiar HIM operations management data that their members can use
with an external audit, this is a standard practice at many large for analytics and evidence to support operations. AHIMA could
organizations. External auditors examine different practices and become a source of benchmarks and a resource for the health-
processes in the organization to ensure accuracy and compli- care industry. x
ance with regulations. All of the transcription data was reviewed
for accuracy. The data collection sources were examined, as Notes
were the numbers reported. Due to the documentation support- 1. AHIMA Data Quality Management Task Force. 1998. “Data
ing the processes and the data collected, there were no recom- Quality Management Model (1998) - Retired.” Data Quality
mendations for improvement. Management Model (1998) - Retired / AHIMA, American
It is also useful to note, while the current dashboard used by Health Information Management Association, June. http://
this healthcare delivery system is remarkable, it has evolved bok.ahima.org/doc?oid=105639.
over the course of several years to meet the business needs 2. Wang, Tiankai, and Jackie Moczygemba. 2018. “Analyzing
of the organization and to align with enterprise strategic ICD-10 Diagnosis Codes with Stata.” Analyzing ICD-10 Diag-
goals. The dashboard not only contains data from a system nosis Codes with Stata / AHIMA, American Health Informa-
perspective, it also contains data at the hospital level, allow- tion Management Association, May. http://bok.ahima.org/
ing transparency and benchmarking. It was important to the doc?oid=302491.
organization to create a culture of transparency which dem- 3. Czahor, Amy. 2017. “How Analytics Can Direct and Improve
onstrates the value of a centralized HIM model. Dashboard Clinical Documentation.” Journal of AHIMA 88 (9): 36–39.
data are used by leaders across the enterprise to identify 4. Butler, Mary. 2018. “Niche Analytics.” Niche Analytics / AHI-
patterns/trends and as an internal comparison with similar MA, American Health Information Management Association,
size hospitals. This level of transparency has created a true October. http://bok.ahima.org/doc?oid=302586.
partnership for improvement on specific measures between 5. Thomas, Felicia A., and Wahiyda A. Harding. 2018. “Data
HIM and other departments within the organization. The Analytics: The Power of Coded Data.” Data Analytics: The
dashboard has allowed improvement in HIM operations and in Power of Coded Data / AHIMA, American Health Informa-
quality outcomes through collaborative efforts across the en- tion Management Association, October. http://bok.ahima.
terprise. It has been reported on more than one occasion that org/doc?oid=302591.
stakeholders look for the monthly dashboard and appreciate 6. Houser, Shannon H., Donna J. Slovensky, and Luona Wang.
the level of transparency. 2017. “Information Governance for Analytics Support: Re-
HIM professionals wishing to initiate a dashboard should member the Life Cycle Component.” Journal of AHIMA 88
choose a starting point. This starting point could be with a single (6): 38–40.
measure or a single organizational unit. For example, coding 7. Clack, Lesley, Shannon H. Houser, Lesley Kadlec, Ray-
might be reasonable since HIM departments commonly track mound Mikaelian, Annemarie Wendicke, Jeannine MSHI
their coding productivity. Once this reporting is standardized Cain, and Amanda MA Spears. 2018. “Best Practices for
and everyone is comfortable with the reporting, additional units Data Analytics Reporting Lifecycles: Quality in Report
such as release of information or documentation compliance can Building and Data Validation.” Best Practices for Data
be added until all operations under HIM supervision have KPIs Analytics Reporting Lifecycles: Quality in Report Building
included on the dashboard. and Data Validation / AHIMA, American Health Informa-
tion Management Association, October. http://bok.ahima.
Conclusion org/doc?oid=302585.
This case study is the first thorough examination of evidence- 8. Stanfill, Mary. 2019. “In Pursuit of Comparable Coding Audit
based HIM operations management. As such, it exposes both Benchmarks.” Journal of the American Health Information
challenges and benefits of using data to manage operations. Ini- Management Association 90 (1): 30–31, 47.
tial challenges include securing employee cooperation for a new
management process, efficiently collecting the data, and produc- Susan H. Fenton is associate professor and associate dean for academ-
ing the dashboard in a timely fashion. Benefits include substan- ic affairs, at the University of Texas Health Science Center at Houston
tiation of HIM operations effectiveness, HIM employee pride in School of Biomedical Informatics, in Houston, TX. Diann H. Smith is vice
their jobs, and validation of HIM reporting when under internal president, health information management services and clinical docu-
or external review. mentation improvement, at Texas Health Resources, in Arlington, TX.

Journal of AHIMA March 20/ 35


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