SPECIAL FOCUS SECTION: PATIENT SAFETY/QUALITY IMPROVEMENT Patient Safety/Quality Improvement Improved Comorbidity Capture Using a Standardized 1-Step Quality Improvement Documentation Tool Otolaryngology– Head and Neck Surgery 2018, Vol. 159(1) 143–148 Ó American Academy of Otolaryngology–Head and Neck Surgery Foundation 2018 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599818764669 http://otojournal.org Robert J. Morrison, MD 1,2 , Kelly M. Malloy, MD 3 , and Rishi R. Bakshi, DO 4 No sponsorships or competing interests have been disclosed for this article. Abstract Objective. To assess the impact of implementation of a ‘‘1-step’’ documentation query system on comorbidity capture and qual- ity outcomes within the Department of Otolaryngology–Head and Neck Surgery. Methods. Implementation of the 1-step documentation query system was instituted for all otolaryngology–head and neck surgery faculty at a single institution. Individual query responses and impact metrics were analyzed. Departmental case-mix index (CMI), risk of mortality (ROM), and severity of illness (SOI) were collated over a 14-month implementation period and compared to a 12-month preimplementation period. Results. A total of 226 documentation queries occurred during the program pilot period, with an 86.7% response rate. Of queries with a response, 91.0% resulted in a signifi- cant impact for the hospitalization diagnoses-related group, ROM, or SOI. Departmental CMI increased from 2.73 to 2.91 over the implementation period, and observed/ expected mortality ratio decreased from 0.50 to 0.42 pre- to postimplementation. Discussion. With increasing emphasis on quality metrics out- comes within the United States health care system, there is a need for institutions to accurately capture the complexity and acuity of the patients they care for. There was a positive change in quality outcomes metrics, including ROM, SOI, and CMI over the first year of deployment of the 1-step documentation query process. Implications for Practice. Clinical severity metrics are becoming increasingly important to otolaryngologists, as insurers move to severity-adjusted profiles. The 1-step documentation query process provides a reproducible and effective way for clinical documentation specialists and physicians to collaborate on improving departmental clinical severity metrics. Keywords PS/QI, diagnosis-related groups, value-based purchasing, outcomes, coding, case-mix index, comorbidities, documentation query, inpatient medicine, risk adjustment, electronic medical record Received November 21, 2017; revised January 16, 2018; accepted February 21, 2018. A ccurate documentation of the nature of a patient’s clinical course during hospitalization has been essential for patient care since the advent of the modern hospital. Documentation serves to aid the patients and their physicians both during the admission as well as when the patients transition into the outpatient world. With the proliferation of Diagnosis-Related Groups (DRGs) in the 1960s and subsequent tethering to Medicare in 1982, there has been an inevitable linking between documentation and medical resource allocation. 1 To date, DRGs remain the gold standard for health care systems-level risk-adjusted outcomes data and remain essential to health care purchas- ing negotiation and institutional prestige in metrics such as the US News & World Report Rankings (USNWRR). 2 With an ever-increasing emphasis on pay for performance and value-based purchasing within the US health care system, there is a pressing need for institutions to accurately capture both the complexity and acuity of the patients they care for. US hospital adoption of ‘‘comprehensive’’ electronic medical record (EMR) systems, defined as an EMR capable of meeting all core meaningful use metrics, including eva- luation and tracking of quality metrics, has been steadily 1 Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, USA 2 Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA 3 Division of Head and Neck Oncology and Microvascular Surgery, Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, USA 4 Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA Corresponding Author: Rishi R. Bakshi, DO, Department of Physical Medicine and Rehabilitation, University of Michigan, 325 E Eisenhower Parkway Suite 100, Ann Arbor, MI 48108, USA. Email: rbakshi@med.umich.edu