Clinical coding and the quality and integrity of health data

A Model for Clinical Coder Satisfaction in Saudi Arabia Based on a Holistic Approach: Clinical, Professional and Organizational Dimensions

The quality of clinical coding influences not only hospital revenue but also the quality and efficiency of healthcare services. Assessing the coders' satisfaction is essential to optimizing the quality of clinical coding. This mixed-method study used a qualitative approach to propose the study model while testing the model through a quantitative approach. The relevant variables of the satisfaction model were assessed through a survey targeting clinical coders across the country on a timely basis. Fourteen experts participated in establishing the model with three dimensions: professional, organizational, and clinical. Each dimension has its relevant variables. One hundred eighty-four clinical coders participated in phase two. 34.5% were male, 61% held a diploma, 38% had a bachelor's and above, and 49.7% worked in hospitals having fully electronic health records. We found that organizational and clinical dimensions strongly correlate with coders' satisfaction. Noticeably, the most influencing variables were the availability of coding policies and the computer-assisted coding (CAC) system. The results show that the model explains the satisfaction of the clinical coders, and organizational and clinical-related variables are crucial. Although gender-based differences exist, training (regardless of the training mode), coding policies, and the CAC system substantially influence coders' satisfaction. A significant stream of the literature supports these findings. However, attempting a holistic approach to assess coders' satisfaction and affecting coding quality is the added value of this study. Optimizing clinical coding practice requires organization-wide initiatives and policies to regulate coding practices and standards to promote the quality and timeliness of clinical documentation. Training is indispensable not only for clinical coders, but physicians also need to understand the rationale and value of clinical coding. Better utilization of the outcomes of the coding process and adopting the CAC system are significant drivers to enhance coders' satisfaction.

Clinical Coders' Perspectives on Pressure Injury Coding in Acute Care Services in Victoria, Australia

Pressure injuries (PIs) substantively impact quality of care during hospital stays, although only when they are severe or acquired as a result of the hospital stay are they reported as quality indicators. Globally, researchers have repeatedly highlighted the need to invest more in quality improvement, risk assessment, prevention, early detection, and care for PI to avoid the higher costs associated with treatment of PI. Coders' perspectives on quality assurance of the clinical coded PI data have never been investigated. This study aimed to explore challenges that hospital coders face in accurately coding and reporting PI data and subsequently, explore reasons why data sources may vary in their reporting of PI data. This article is based upon data collected as part of a multi-phase collaborative project to build capacity for optimizing PI prevention across Monash Partners health services. We have conducted 16 semi-structured phone interviews with clinical coders recruited from four participating health services located in Melbourne, Australia. One of the main findings was that hospital coders often lacked vital information in clinicians' records needed to code PI and report quality indicators accurately and highlighted the need for quality improvement processes for PI clinical documentation. Nursing documentation improvement is a vital component of the complex capacity building programs on PI prevention in acute care services and is relied on by coders. Coders reported the benefit of inter-professional collaborative workshops, where nurses and coders shared their perspectives. Collaborative workshops had the potential to improve coders' knowledge of PI classification and clinicians' understanding of what information should be included when documenting PI in the medical notes. Our findings identified three methods of quality assurance were important to coders to ensure accuracy of PI reporting: (1) training prior to initiation of coding activity and (2) continued education, and (3) audit and feedback communication about how to handle specific complex cases and complex documentation. From a behavioral perspective, most of the coders reported confidence in their own abilities and were open to changes in coding standards. Transitioning from paper-based to electronic records highlighted the need to improve training of both clinicians and coders.