Good practice from 2008/09 audits
Areas of good practice
Clinical coding and data quality group.
Background
The Trust set up the Clinical Coding and Data Quality Group in late 2007 to provide support for improving coding and data quality. It has since expanded its remit to include trust-wide data quality issues.
Objective
To improve the recording, capture and coding of patient data.
Outline
The recently reviewed Terms of Reference state that the purpose of the group is to involve champions from all areas of the Trust in issues which impact on data quality. By doing this, the group should create more accurate recording, capture and coding of patient data.
Membership includes the medical director (chairman), all divisional managers, a consultant from each division, clinical coding service and data quality managers, the medical records manager, patient access manager, electronic patient records manager, and information manager. It also includes representatives from finance, governance, wards (clerks), outpatients and A&E.
Some of the agenda items are rolling items the group checks constantly. These include:
- The quality and consistency of the discharge summary.
- PbR audit recommendations (current issue R6: The Trust should draw up a clear set of guidelines for recording clinical information)
- Real-time bed management.
- Consultant engagement in data quality.
- Updates on new electronic data capture systems and how to implement their use to the greatest benefit.
Other agenda items are introduced as they occur and are quickly resolved.
These have included:
- Reorganising the data capture process for specific areas of the Trust. The Trust has recorded successes in capture of inpatient maternity details, trauma and orthopaedics episodes and transitional care babies.
- Assessing the financial and coding impact of poorly recorded data. This has led to the successful resolution of problems with data recording for both medical and surgical divisions.
Impact
The Trust states that general impacts of the Clinical Coding and Data Quality Group are:
- Better communication and an improved understanding of the interrelationships between key trust functions.
- Improved consultant and clinician engagement with the coding process.
- An improved drive to get data right the first time in all areas of the Trust.
- An overall raised awareness of the need for a culture which values data quality.
Source: Tribal and Mid Staffordshire NHS Foundation Trust