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Centers for Medicare & Medicaid Services provides reimbursement through Hierarchical Condition Category (HCC) coding. Medical systems strive toward risk adjustment optimization, often implementing costly chart review processes. Previously, our organization implementing countermeasures through workflows was complex and performed in silos. Our goal was to put in place HCC-Risk Adjustment Factor (RAF) improvement tools to optimize HCC-RAF management in Population Health using rapid process improvement methods. In this quality improvement analysis (IRB#806198), we used Lean methodology to develop tools and implement streamlined processes for providers to manage, document, and code high-risk HCC conditions. Rather than applying costly countermeasures, Transformational Healthcare conducted a Rapid Process Improvement Workshop (RPIW), with workgroups implementing proposed changes, to improve processes. Each of these tools was embedded in standard work, for teams to use in practice. Tools included the development of RPIW-inspired work groups, a Provider Education website, tip sheets, clinical champions, trainings, audits, practice alerts, smart phrases, schedule view tools, severity scores, reports, dashboards, on-screen decision-support tools, coding expertise, and HCC standard work. Quantitatively, Year 1 showed enterprise HCC-RAF scores improved by 4.1%. We were able to develop tools for providers and team members to allow for more optimized pathways. Although quantitatively we realized an improvement in enterprise HCC-RAF score, our overall aim was to improve process flow and limit waste. Leveraging Lean improvement methods for the collective design of tools has supported culture change. In the end, we found that providers are indeed willing to adopt these newly built tools. These tools have optimized operations, allowing providers to work smarter, not harder.

Background: Stroke is a worldwide problem with a limited number of approved treatments. Obtaining informed consent for acute stroke therapy is complicated by the breadth of information that must be communicated in a short period of time, the hectic nature of the emergency environment, the possible lack of understanding by the patient and/or family, and the critically time-sensitive nature of treatment for stroke. Complicating matters even further, patients are often unable to consent for themselves, placing the burden on surrogates to infer patients' wishes regarding treatment, and potentially limiting acute treatment by practitioners., Innovation: An advance directive for acute stroke therapy was created, entitled COAST (Coordinating Options for Acute Stroke Therapy). This clinical initiative is being piloted at a large comprehensive stroke center, including the development of the advance directive form, integration of the form with electronic medical records, training healthcare providers, and outreach to patients., Conclusions: COAST is an advance directive for stroke designed to make stroke care more efficient, optimize patients' autonomy, improve the quality of healthcare, and streamline the ethical management of complex care decisions in acute stroke. The inherent benefit of COAST is in providing patients and their families with more information regarding stroke and its treatment options, allowing them to take a more active role in their care., (Copyright 2015 The Journal of Clinical Ethics. All rights reserved.)