Improving Quality Metrics in Neurosurgery: A Spinal Surgery 3-Year Case Review

Despite the known importance of accurate clinical documentation as a companion to quality patient care, this is not often prioritized in practice and leads to a variety of downstream consequences. Inaccurate documentation leads to missed opportunities in full, accurate coding. In turn, it also negatively influences hospital and physician quality ranking, medical center profiling, and revenue captured. The aim of this study is to highlight the opportunity for continuous improvement in clinical documentation and the significance accurate clinical documentation has on outcome measures, such as expected length of stay (eLOS).

A single-center retrospective chart review took place for patients undergoing spinal surgery from 2019 to 2021. Based on Vizient's diagnosis-related group risk model for eLOS, 192 charts spanning 10 unique diagnosis-related groups were reviewed to identify ICD-10 diagnosis and procedure codes that were not coded or not clearly documented by a physician. A new eLOS for each patient was recalculated with the addition of the newly identified variables and then compared with the original eLOS.

Overall, there was a significant difference between the original eLOS and new eLOS when the newly identified variables were added (P < .001). Of 192 patient charts, 89.5% had at least one new variable contributing to eLOS, with an average of 2.60 (0, 12) new variables. This resulted in an average increase in eLOS of 2.869 days (-0.160, 35.129). Compared with the observed LOS, the new eLOS was significantly different (P < .001), whereas the original LOS was not (P = .5661).

Incomplete documentation and coding can misrepresent the quality of patient care provided and the complexity of their cases. This represents an opportunity for improvement for both the clinicians, clinical documentation improvement specialists, and coders to improve quality metrics and hospital rankings.