The Importance of Accurate Documentation in Tracking Hospital-Acquired Conditions

At GBMC HealthCare, we have made it a priority for many years to track and reduce rates of hospital-acquired conditions as part of our quality and safety initiatives. These conditions can include infections like urinary tract infections, surgical site infections, bloodstream infections, pneumonia, and other complications like pressure ulcers or falls that were not present at the time the patient was admitted. They are considered preventable in many cases through proper infection control measures and patient safety protocols. 

Proper documentation is critical to our ability to accurately identify incidents of hospital-acquired conditions and take the necessary steps to investigate how they happened and how to prevent them in the future. 

The Maryland Hospital-Acquired Conditions (MHAC) program is a state initiative aimed at reducing the incidence of preventable hospital-acquired conditions. It incentivizes hospitals to improve patient safety and quality of care by implementing strategies to prevent specific adverse events, such as infections and injuries occurring during hospital stays. Hospitals are financially rewarded or penalized based on their performance in preventing these conditions, encouraging continuous improvement in patient safety measures.  

In some cases, a condition is deemed an MHAC not because of the clinical care of the patient, but rather, because of lack of efficient documentation that the issue was present before the patient was admitted to the hospital. In these situations, the MHAC is not truly reflective of the quality and safety of our patient care and is more indicative of incomplete documentation. 

To make sure our data reflects true hospital-acquired conditions and not ones that were already present on admission, our teams have been working hard toward documentation improvement. This work includes identifying trends with both documentation and clinical practice by our Quality and Coding Collaborative, chart reviews to validate clinical conditions, documentation that best defines the patient condition and associated questions to providers if further definition of a patient condition is required. Education to clinicians and resources to support their documentation is available to further assist our efforts for improvement. 

Although it is too early to share specific data, the collaboration of our coding and quality teams to promote education, communication and documentation support have shown promising preliminary results. 

Thank you to the team leading this charge, including John “Jack” Flowers, MD, Executive Vice President and Chief Medical Officer; Joseph M. Fuscaldo, MD; Medical Director of Quality Improvement; and Denise Kosmas, RN, Clinical Documentation Improvement Specialist. 

Your efforts help us ensure we investigate true cases of hospital-acquired conditions while not being penalized for those present on admission. 

A Piece of History
Yesterday morning, I was surprised by a visit from Tracy Hickman, LPN, CHPLN – Gilchrist, who brought a very unique gift. While browsing a church sale, she came across a framed invitation for the original ribbon cutting of Greater Baltimore Medical Center in October of 1965! The piece invited the intended recipient to join former President Dwight D. Eisenhower and his brother Milton Eisenhower for the dedication of the hospital. Thank you, Tracy, for sharing this piece of history! We look forward to displaying it on campus in the future, alongside other items from GBMC’s past. 

National Hospitalist Day
March 7 was National Hospitalist Day! Hospitalists provide comprehensive, general medical care to hospital patients 24/7 during their stay. Thank you to our hospitalists for all you do to care for our patients and their families.

International Women's Day
Today (March 8) is International Women's Day, a global day celebrating the social, economic, cultural, and political achievements of women. The day also marks a call to action for accelerating women's equality. Join GBMC HealthCare in recognizing International Women's Day and Women's History Month throughout March!