Background: It is essential that clinical documentation and clinical coding be of high quality for the production of healthcare data.
Objective: This study assessed qualitatively the strengths and barriers regarding clinical coding quality from the perspective of health information managers.
Method: Ten health information managers and clinical coding quality coordinators who oversee clinical coders (CCs) were identified and recruited from nine provinces across Canada. Semi-structured interviews were conducted, which included questions on data quality, costs of clinical coding, education for health information management, suggestions for quality improvement and barriers to quality improvement. Interviews were recorded, transcribed and analysed using directed content analysis and informed by institutional ethnography.
Results: Common barriers to clinical coding quality included incomplete and unorganised chart documentation, and lack of communication with physicians for clarification. Further, clinical coding quality suffered as a result of limited resources (e.g. staffing and budget) being available to health information management departments. Managers unanimously reported that clinical coding quality improvements can be made by (i) offering interactive training programmes to CCs and (ii) streamlining sources of information from charts.
Conclusion: Although clinical coding quality is generally regarded as high across Canada, clinical coding managers perceived quality to be limited by incomplete and inconsistent chart documentation, and increasing expectations for data collection without equal resources allocated to clinical coding professionals.
Implications: This study presents novel evidence for clinical coding quality improvement across Canada.
Keywords: administrative data; clinical coding; data quality; health data; health information management; qualitative research; quality improvement.