Teamwork in Action: Bridging Gaps with Clinical Documentation and Coding - 2025 Quality Summit Presentation (Non-CE)-Teamwork in Action: Bridging Gaps with Clinical Documentation and Coding

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Video Summary

In the "Teamwork in Action: Bridging Gaps with Clinical Documentation and Coding" session, Kim Shea, Cardiovascular Quality Coordinator at Baptist Health Louisville, shared her journey and strategies for enhancing cardiovascular care through effective concurrent review and collaboration between clinical documentation and coding teams. With over 23 years in nursing and extensive leadership in quality improvement, Kim described how her role evolved from bedside nursing to overseeing cardiovascular accreditation and data management.<br /><br />She emphasized the power of concurrent review—evaluating patient care and documentation in real-time during hospitalization to quickly identify and address care or documentation gaps. Beginning with focused review of STEMI cases, they expanded to non-STEMI, medication reconciliation, and cardiac rehab referrals, showing measurable improvements such as increased defect-free care from 51.6% to above 90% and mortality reduction from 6.2 to 4.3. Key drivers included fostering multidisciplinary teamwork, leveraging existing workflows, educating clinical documentation improvement (CDI) and coding teams on cardiovascular nuances, and streamlining provider communication.<br /><br />Challenges remain in resource allocation, sustainable staffing, provider buy-in, and aligning clinical documentation with evolving coding guidelines, especially around complex diagnoses like type 2 MI versus NSTEMI. Kim highlighted the importance of incremental implementation, prioritizing high-impact metrics, transparent communication, peer accountability, and continuous education.<br /><br />The session underscored that successful concurrent review requires adaptable processes tailored to organizational context, with leadership support obtained through data-driven demonstrations of impact across quality platforms. Kim offered practical advice on managing documentation queries, collaborating across departments, and involving provider champions to sustain improvements. Her approach illustrates how a committed quality team in a community hospital can leverage teamwork and data integration to elevate patient outcomes in cardiovascular care.

Keywords

public reporting

cardiovascular healthcare

National Cardiovascular Data Registry

healthcare quality measurement

transparency in healthcare

risk aversion

clinical registries

hospital rankings

ethical medical practice

transcatheter aortic valve replacement

Teamwork in Action

Clinical Documentation

Coding

Cardiovascular Care

Concurrent Review

Quality Improvement

STEMI and Non-STEMI

Multidisciplinary Collaboration

Provider Communication

Patient Outcomes