Clinical Coders Under Pressure: Are They at Risk of Burnout and a Form of Compassion Fatigue?

Clinical Coders under pressure: are they at risk of burnout and a form of compassion fatigue?

Felicity Best

Clinical Coders (CCs) become the bystanders of a patient’s journey through the hospital system. They are required to read a large amount of clinical documentation in order to abstract the diagnoses and procedures and translate this information into codes. Much emphasis is placed on CC performance, especially in the areas of quality and output, and while these are important, the emotional aspects of the job appear to have been overlooked. This article illustrates that the changing demands on the coding workforce since the advent of activity- based funding has made them vulnerable to the possibility of burnout and a form of compassion fatigue.

Activity-based funding The advent of activity-based funding (ABF) has “rocked the clinical coding world”. CCs went from relative obscurity to having a fundamental role in the hospital system, dealing with clinicians, management, and other stakeholders on a regular basis (Shepheard, 2017). The accuracy of the coded data is critical to the success of the ABF model and it is understand- ably a priority for all health services to ensure high quality and timely coded data. This is especially apparent in the private CCs read a great deal of information in the course of health system where CCs can find themselves in the middle their daily work. In an (unpublished) 2009 3M Codefinder of two stakeholder groups who both have the absolute right Software National User Group meeting, Leon Paff stated for accurate DRG information, but who have different agendas; that on average a CC will read between 720 and1,440 pages namely the hospitals that employ them and the private health of clinical documentation per day, which is equivalent to insurance funds. CCs must rely on their professional code of three to four novels. The CC’s role is to translate the clinical ethics to ensure accurate code assignment, which is used for statements documented during an inpatient stay into alpha- optimal financial reimbursement for the hospital, while at the numerical codes using a clinical classification system known same time be cognisant of the private health insurance funds’ as the International Statistical Classification of Diseases requirements. This means CCs must be confident that the and Related Health Problems-Tenth Revision-Australian clinical documentation has provided the evidence for their Modification (ICD-10-AM). These codes are then grouped coding decisions. Private health insurance funds regularly ask together into Australian Refined Diagnosis Related Groups for further documentary evidence to substantiate code and (AR-DRGs), and are used extensively in health management DRG assignment. Many of the larger private health insurance and practice for hospital financial reimbursement, research, funds also conduct annual coding audits of reimbursed hospi- health service predictions, and planning. As reliable analysis talisations. Therefore, clarity of documentation is essential for requires data accuracy, CCs are expected to provide accurate accurate coding and DRG assignment. When the documen- code assignment based on what has been documented in the tation is unclear or ambiguous, the CC is required to seek clinical record, including medical conditions and interventions. further information from the clinician. One code erroneously Consequently, CC performance has come under increased added or missed can change the DRG. scrutiny, particularly in the areas of quality and productivity, Coding audits from private health insurance funds are not and the emotional aspects of the profession are sometimes the only audits CCs experience. In addition to its critical role overlooked. in ABF, coding accuracy is also essential for the operational management of health facilities and reporting of hospital morbidity data. Therefore, to ensure coding accuracy hospitals can routinely undergo internal and external coding audits, with the CCs being held accountable for the outcomes of these

HIM-INTERCHANGE Vol 7 No 3 2017 ISSN 1838-8620 (PRINT) ISSN 1838-8639 (ONLINE) 29 PERSONAL PERSPECTIVE

CCs ... are inadvertently exposed on a daily basis to the difficult experiences some patients face in their aim for recovery and wellness, or on the other continuum, a peaceful death

audits (Shepheard, 2017). Auditing may be conducted on a sonalisation, where clients or patients are viewed as objects quarterly to annual basis, where auditors examine a random rather than people; and a negative sense of personal accom- sample of coded admissions by individual CCs and the results plishment. Factors such as work overload and time pressures are discussed with that CC. Anonymous collective feedback can be contributing factors, and Portnoy (2011) went on to can also be shared with the group and provides ongoing argue that ultimately burnout results in symptoms of somatic education. complaints, social withdrawal, and irritability. However, they Productivity may be monitored on an individual and collec- also stated that “it is not possible to say that all people tive basis. CCs may have their own key performance indicators working in a certain occupation will experience the same (KPIs) for coding throughput. This may range from 15 to 42 amount of stress”. This is dependent on their personality type records per day, depending on experience (Santos et al., 2008). and available support mechanisms. Feedback can be provided on a monthly to annual basis where Stansfeld & Candy (2006) described the increased risk of the individual CC is provided with information pertaining to mental health disorders where high job strain is recognised. his or her productivity and accuracy based on audit results for A job with high psychological demands, particularly if this is that period. Therefore, it goes without saying that audits and coupled with little control over work decisions, is consid- KPIs are always in the back of the CC’s mind! ered high strain work. However, they also acknowledged personality style as a moderating factor. Slatten et al. (2011) suggested that burnout occurs when stressors are unrelenting and like Johnson et al. (2005) agreed that “emotional exhaustion occurs when the employee feels psychologically over extended and fatigued by the work”. While there is much published research on the risk of burnout in the helping professions, this writer could not find any reference pertaining to the clinical coding profession; CCs as bystanders of the patient’s however, based on the current context, it could be inferred journey that CCs are at risk of burnout. CCs may be at risk of CCs become the bystanders of a patient’s journey through the burnout as a result of: hospital system. This involves careful scrutiny of clinical docu- The constant scrutiny on accuracy and productivity which mentation in the medical record to ensure that the diagnostic may manifest into an inflated perceived ‘pressure to and intervention detail is abstracted and coded to group to an perform’ on a daily basis accurate DRG. CCs may encounter a varied casemix. Cases Feeling their clinical coding practices are being challenged can range from minor day procedures to complex surgery, from varying stakeholders major trauma, and medical illness from all specialities. CCs Having little control over their desired work practices may read extensive and often complex clinical documenta- which are being driven by the financial needs of the tion related to a patient’s hospitalisation, with a length of stay hospital and other reporting requirements, or ranging from a day to months, even years. Therefore, they The work requires a high level of concentration, are inadvertently exposed on a daily basis to the difficult particularly with complex cases. experiences some patients face in their aim for recovery Therefore, it would seem that clinical coding could be and wellness, or on the other continuum, a peaceful death. considered a job with high psychological demands. It must be noted that while CCs legitimately need access to the clinical documentation within medical records in order to Compassion fatigue perform their role, they should abide by a professional code of Compassion fatigue was described by Mathieu (2007) as an ethics and patient confidentiality should be strictly adhered to occupational hazard for helping professionals and the price and maintained at all times. they pay when caring for others in “emotional and physical pain”, regardless of the intrinsic rewards that go with the Burnout work. Slatten (2011) believed that employees find fulfillment Burnout is described by Slatten et al. (2011) as a “construct” and satisfaction in meeting the needs of patients, but when that progresses slowly, and according to Johnson et al. (2005) constantly exposed to the trauma of others it can become is comprised of three elements: emotional exhaustion; deper- difficult to maintain a healthy balanced life. While the literature

30 HIM-INTERCHANGE Vol 7 No 3 2017 ISSN 1838-8620 (PRINT) ISSN 1838-8639 (ONLINE) relates compassion fatigue to the helping professions that Conclusion provide face-to-face and hands-on care to patients, Portnoy Clinical coding can be an interesting, challenging, and rewarding (2011) suggested that repeated exposure to people’s suffering career choice. However, as Shepheard (2017) noted, CCs can lead to a heightened sense of vulnerability. are working under very changed conditions since the advent Portnoy (2011: 48) argued that compassion fatigue is of ABF. As a result of these changed conditions, it could be derived from empathy and is a “natural consequence of stress suggested that CCs are at risk of burnout, with the possible resulting from caring for and helping traumatized or suffering consequences of absenteeism and/or mental health issues, people”. He also pointed out that the carer does not need to staff reducing their working hours, and resignations in what witness the event but that “simply being exposed to another is already a seemingly depleted workforce. The impact of the person’s painful narrative can be enough” (p. 48). Mathieu more emotional aspects of the job is an area that seems to (2007) cited Remen (1996) in stating that “the expectation have gone unnoticed and research may help to determine if that we can be immersed in suffering and loss daily and not be this is an aspect that needs addressing. touched by it is as unrealistic as expecting to be able to walk through water without getting wet”. Acknowledgements It is not this writer’s intention to suggest that CCs are I would like to thank my Manager, Letalia Thornberry, under the same stressors as those in the front line helping and Deputy Manager, Jong (JJ) Jung, for their support and professions. However, by way of their profession, CCs are encouragement with this article, especially JJ for his graphics exposed through the written word to the health challenges contribution, and my CC colleagues for their continued inspi- some patients experience and it would seem unrealistic to ration suggest that as individuals they would be completely immune to the effects that this may have on their emotional wellbeing. References Like burnout, the possibility of a form of compassion Johnson S, Cooper C, Cartwright S, Donald I, Taylor P and Millet C (2005) fatigue is difficult to determine as there appears to be no The experience of work related stress across occupations. Journal of published research related to the clinical coding profession on Managerial Psychology 20(2): 178–187. this topic. Matthieu F (2007) Running on empty: Compassion fatigue in health Questions that come to mind when thinking about this professionals. Rehab & Community Care Medicine (Spring). Available subject include: at: http://www.compassionfatigue.org/pages/RunningOnEmpty.pdf (accessed 14 Aug 2017). Do CCs feel a sense of psychological or emotional fatigue Portnoy D (2011) Burnout and compassion fatigue. Watch for the signs. when coding repetitive complex cases and/or records Journal of the Catholic Health Association of the United States Health of deceased patients? If so, how does this actually affect Progress, 47-50. Available at: www.compassionfatigue.org/pages/ them? healthprogress.pdf (accessed 14 Aug 2017). Are they able to emotionally detach from what they are Santos S, Murphy G, Baxter K and Robinson KM (2008) Organisational reading or do they find themselves identifying in a way factors affecting the quality of hospital clinical coding. Health with patients who have serious illnesses? Information Management Journal 37(1): 25-37. Is age a factor? Do older CCs identify more with the Shepheard J (2017) How activity based funding models impact on the vulnerability of ill health? clinical coding workforce. HIM-Interchange 7(1): 5-7. Can hypochondriasis develop over time, where CCs Slatten LA, Carson KD, and Carson PP (2011) Compassion fatigue and become anxious about their own health based on what burnout: What managers should know. The Health Care Manager 30(4): 325-333. they consistently read? Stansfield S and Candy B (2006) Psychosocial work environment and Are they able to disengage at the end of their working day, mental health: a meta-analytic review. Scandinavian Journal of Work, or does the memory of a patient’s experience linger in Environment and Health 32(6; special issue): 443-462. their minds? Is there a difference for CCs working in the public health system compared with the private health system?

Reducing the risk The possible risk of burnout and a form of compassion fatigue in the clinical coding profession may be reduced by: CCs having control over their work practice and pace; for instance, ensuring all CCs, regardless of experience, have variety in their daily workloads so that complex cases are regularly interspersed with more routine cases, Felicity Best, BAppSci(HIM), MCouns or allocating the last hour of the day to simpler cases, for Clinical Coder example, day procedures Hollywood Private Hospital Encouraging CCs to have a better understanding of the Health Information Services different stakeholder’s requirements email: [email protected] Providing the opportunity for CCs to de-brief. www.ramsayhealth.com.au

HIM-INTERCHANGE Vol 7 No 3 2017 ISSN 1838-8620 (PRINT) ISSN 1838-8639 (ONLINE) 31