Case Study

Below, serves an example of a remote clinical coding service delivery, on behalf of a major London-based NHS Trust. The case study highlights the scope of the contract, how it has expanded through the provision of a high-quality service, and importantly the outcomes produced.

Contract background:

  • The Trust offers a wide range of acute medical services.
  • Services are provided via four main hospital locations.
  • Following its market engagement for a remote coding solution, the Trust selected CEC as its delivery partner. At the time, it was facing many challenges within its clinical coding departments due to staff turnover and inability to recruit from the local talent pool. Agency staff had been employed to supplement the in-house teams, but a lack of continuity and certainty on supply of resources presented an unwelcome scenario for the coding management team. Also, of concern, was the cost of supplementing coding activities with Agency staff.
  • The contract with CEC governs the supply of a managed service for remote clinical coding, covering all clinical services provided, for both inpatient and outpatient episodes of care.
  • For inpatient stays, CEC clinical coders are required to access Trust systems remotely, which entails some 14 network applications.
  • For outpatient outcome forms, CEC manages the secure collection, sifting and coding offsite via its administration offices in Gloucester.
  • KPIs focus on meeting monthly deadlines, volume and depth of coding and income optimisation.
  • Specialties and volumes of FCEs are allowed to fluctuate monthly; approximate volume targets are agreed on a rolling basis.
  • Monthly reporting identifies performance against coding lists provided.
  • CEC self-serves from the lists provided.
  • At all times, CEC operates as a data processor as defined under data protection legislation, including the EU GDPR. The Trust acts as the data controller. The contract extends to a data processing agreement signed by the parties, covering access to trust data and incorporates local IG and IT policies. Subsequently, this was amended to accommodate latest UK Data Protection Law and the EU GDPR.
  • Given the scale of activities, it was essential that the service provider could offer a service that flexed in line with demand management generated by the hospital workload.

Pre-delivery risk assessment

Prior to setting up the managed service, CEC operated against a check list to aid in minimising and mitigating delivery risk. Risks were categorised within seven areas:

  • Customer requirement capture, and delivery mapping
  • Team resource appointment
  • Customer engagement, with focus on IT and training
  • Establishing connectivity
  • Undertaking training
  • Testing readiness
  • Going live

The overall risk score was low. Programme management monitored progress against the steps outlined, up to go-live; any deviation from expected outcomes triggered interventions to ensure escalations were conducted as required.

Contract delivery

At the outset, CEC appointed two senior team members to act as the account leads, each allocated to individual hospital sites.

Based upon the anticipated volume of coding work, a number of clinical coders were appointed to support the account leads; each team comprises sufficient resources to guarantee delivery against forecast volumes, and to accommodate planned and unplanned absence.

CEC was able to set up and engage in contract delivery within a matter of days, following signature of the contract and data processing agreement. All programme dates were agreed with the Trust, in advance.

Quality of service and continuous improvement

From commencement of service delivery, the team leaders completed their documentation, highlighting specific ways of working at the Trust sites; this was shared with the customer. This documentation provided guidelines for the teams to adopt and aided alignment of approach. Documentation has been updated as necessary to support best-practice delivery, throughout the delivery lifecycle, as part of continuous improvement.

On-going monitoring of performance and feedback has also been a key feature of the service. As part of on-going monitoring, we have conducted regular self-audits in accordance with IGT 14.1-505 best practice. Samples of coding work are assessed by both the CEC auditor and the team leader; feedback arising on quality and methods is given to the team members during weekly meetings.

To be anticipated, CEC detected a few minor areas in the beginning where the approach taken by the in-house team differed from that taken by CEC. Very quickly, CEC adapted to the nuances of the Trust’s ways of working. Evaluations on performance demonstrated that over the passage of time, the in-house teams had developed ways of working, built on their own experiences. These processes had taken many years to form, and, what was found to be second nature for the in-house team was not necessarily documented to the nth degree. Accordingly, small tweaks were required in CEC working practice, to get more closely in step with in-house thinking.

Over the medium term, ever-smaller nuances were uncovered and an improved understanding captured and documented. This capture of best practice definition enabled CEC to move closer and closer to being truly in step with both the customer’s ways of working and thinking, i.e. documented and undocumented practices.

Outcomes

  • Service delivery has resulted in strong collaboration and working in partnership. Working relations are rated very highly. Through account management, CEC maintains a complete view on the Trust’s expectations and has delivered consistently in meeting volume and quality targets.
  • The Trust does not suffer from any clinical coding backlogs.
  • There has a been a marked improvement in managing outpatient outcome forms. Prior to the service set up, there were limited controls in place to monitor the number of forms, to monitor whether outcomes were recorded accurately, and to ensure income reflected service provision levels. Reporting has demonstrated a very real rise in numbers of forms processed and resultant income generation.
  • For inpatient clinical coding, monthly volumes delivered by CEC varies between 6,000 and 8,000 episodes of care. On average, CEC codes 6,500 FCEs each month. This average has increased by some fifty percent from contract commencement.
  • For outpatient outcomes, CEC processes circa 20,000 outcome forms per month, and applies coding to circa 15,000 patient records.
  • The CEC team members now apply clinical coding against all specialties offered by the Trust, ranging from complex long stay spinal trauma, through to day-case episodes. Additional specialties have been added to the list, over the term of the contract.
  • Reporting and analysis by CEC on team performance aids the Trust with its own internal reporting on productivity and quality measurement.
  • CEC has delivered a consistent performance in meeting volume and quality of coding across all specialties, month-on-month, since commencement of duties. The service delivery has added certainty to clinical coding output.
  • The Trust has witnessed an increase in its income generation since commencement of the contract.
  • As part of collaboration, CEC assisted in setting up a scanning solution at one hospital location where not all records were available, electronically. This has enabled remote coding for given specialties.
  • CEC has been called upon on several occasions to assist the Trust in meeting major operational challenges. One example entailed the upgrade and cut-over of systems, to align computing across all operations. Due to the coordination and planning, i.e. the transfer of one hospital to the common system, this meant the whole month’s coding had to be undertaken in real time, to permit a seamless cut-over. CEC flexed the service provision and completed over 9,000 episodes for the month in question. This included working evenings and weekends. The Trust successfully concluded the systems upgrades, with no loss of/impact upon income.
  • The Trust has undertaken its own audits covering all clinical coding work. The latest IG audit demonstrates it is achieving level 3 from its clinical coding activities.