Need to improve accuracy of clinical coding

Speaking at the National Office of Clinical Audit (NOCA) Annual Conference, Dr Brian McCullagh, who is based in the Mater Hospital, Dublin, said that monitoring mortality rates in hospitals is one of many important quality improvement measures.

“Analysing this data is crucial for hospital self-appraisal and ultimately patients’ safety and wellbeing,” according to Dr McCullagh.

However, he added that there is a need to record appropriate data that answers specific answers and that the data needs to be accurate.

Dr McCullagh’s talk was based on an Irish audit of respiratory-related mortality. “The interpretation of coding of the principal diagnosis from the clinical notes can be challenging,” he noted.

“Specifically, the appropriate application of the primary admitting diagnosis as COPD/bronchiectasis versus that of pneumonia. Specialist palliative care coding was under-represented, despite ceilings of care and end-of-life discussions with family.”

Dr Brian Creedon, Clinical Lead, National Audit of Hospital Mortality (NAHM), also spoke in relation to the NAHM 2016 annual report.

He referred to the fact that currently, there is no measure for illness severity within the National Quality Assurance Improvement System (NQAIS)/NAHM tool.

The report recommended that the possibility of including an illness severity score and a palliative care speciality clinical code within the NQAIS/NAHM tool should be explored.

The NOCA conference took place in the RCSI in Dublin on 31 January as part of the College’s annual Charter Day series of meetings, which were attended by over 500 members of Ireland’s surgical community. Charter Day commemorates the foundation of the RCSI by a Royal Charter granted by King George III on 11 February 1784.