Clinical Governance e reingegnerizzazione del processo chirurgico. L’esperienza di un Policlinico Universitario [Pitch]

[Autom. eng. transl.] Proper reporting of surgical procedures as well as the efficiency and organizational appropriateness of surgical processes are fundamental components for ensuring the quality and economic sustainability of healthcare and therefore Clinical Governance (CG). To this end, the unambiguous and clear definition of surgical procedures and the appropriateness of the coding and delivery setting of the same is of fundamental importance. This study describes a project aimed at creating a computerized and updated hospital surgical nomenclature as a CG tool to improve the appropriateness of surgical processes and performances and their reporting. The project was started in June 2020 by the management of a Roman University Polyclinic. Each surgical operating unit (OU) was asked to provide, by filling in a specific form, an updated list of the surgeries performed routinely and the ICD9 codes used for their reporting. Approximately 60 meetings were then held between the Hospital Management and the UUOOs to review and standardize the definitions, coding and delivery setting of the surgical procedures to be included in the updated computerized hospital Nomenclator. A total of 1891 interventions were included in the new Nomenclator, reported by 38 surgical UUOOs, of which 845 performed by several UUOOs but having a univocal and standardized definition and coding in the Nomenclator, in order to avoid heterogeneous / inappropriate reporting of the same. 3451 ICD9 codes were used for the coding of the procedures. 4 interventions with 7 ICD9 codes were coded, 20 with 6, 35 with 5, 132 with 4, 212 with 3, 476 with 2, 1012 interventions with a single ICD9 code. The project has led to greater awareness among professionals of the appropriateness of both the organization and the coding of the surgical services provided. This should translate, as expected impact, into a continuous improvement of the quality of care, a greater appropriateness and homogeneity of the coding of surgical services and a more equitable reimbursement of the same, deriving the latter from the containment of under-coding phenomena and from a more adequate economic enhancement of the services themselves, with positive repercussions on sustainability. The computerized Nomenclator therefore represents an effective tool for the re-engineering of the surgical process in a CG perspective, in the pursuit of which the involvement and participation of professionals is an effective strategy.