NAHM Annual Report 2017
The report presents information across six medical conditions: acute myocardial infarction (AMI) / heart attack, heart failure, ischaemic stroke, haemorrhagic stroke, chronic obstructive pulmonary disease (COPD) and pneumonia.
- Clinicians and clinical coders in hospitals are encouraged to cooperate and work together to create clear and complete medical record information and also to validate HIPE coding in order to ensure accuracy between coding classifications and clinical care. This can take place through formal specialty meetings, attendance by clinical coders at clinical meetings, etc.
- Hospital management, through its governance structures such as the Quality and Safety Committees, should actively ensure and, where appropriate, lead and support improvement in data quality.
- Clinicians need to fully and accurately complete discharge summaries (Health Information and Quality Authority, 2012). These should be completed for all patients who are discharged from hospital, including those who die in hospital. Where discharge summaries are used to support coding, they should be complete and consistent with source documentation, and they should contain a definitive diagnosis (using consistent terminology) and all relevant comorbidities.
- Hospitals should review cases with a principal diagnosis of acute lower respiratory infection (unspecified) in order to ensure that this is an accurate diagnosis. Clinicians should use consistent and specific terminology when documenting respiratory diagnoses.
- The possibility of expanding the review of heart failure in order to enable broader benchmarking should be explored by the HSE National Clinical Programme for Heart Failure, working with the NAHM Governance Committee.
- The ‘acute bronchitis’ Clinical Classifications Software (CCS) group in NAHM should be renamed ‘acute lower respiratory infection (unspecified)’ in order to more accurately reflect the majority of cases it contains.
- Hospitals should continue to use the NQAIS NAHM web-based tool to monitor and review their mortality patterns as part of routine quality improvements and learn from their findings.