All Entries in the "Growing your program" Category

Conference Q&A: ‘CDI Career Ladder’

Want to climb the CDI career ladder? Two ACDIS speakers will tell explain how during today's presentations.

Editor’s Note: This post is part of an ongoing series of Q&As with presenters and participants from the 2012 ACDIS Conference in San Diego. The following features Jennifer Love, RN, BA, CCDS, and her  co-presenter Janet Gentle, RN, BSN, MSN, CCDS on the presentation “CDI Career Ladder: Two Perspectives,” which takes place today, Thursday, May 10, 3:15-4:15 p.m.

Q: How long have you been a CDI professional? 

JL: In 2008 I was hired as the manager of CDI for Novant Health.  In 2011, I became the area director of Clinical Documentation Improvement for Kindred Healthcare.

JG: Seven years.

 Q: What inspired you to follow this career path? 

JL: When I was a Surgical Care Improvement Project analyst at Novant, my senior director informed me that the hospital system was considering implementing a CDI program.  In discussions that followed, I was allowed to purchase The Clinical Documentation Improvement Specialist’s Handbook.  I read that book cover-to-cover! I was hooked!  CDI was something fresh; a new challenge which definitely sparked my interest.  I was hired as the manager of Clinical Documentation Improvement and the CDI program was implemented shortly thereafter.

JG: We had consultants who were brought in to redesign our case management (CM) department and establish a CDI program. They encouraged me to interview for the dual CM supervisor/CDI position which, within three years, turned into a full-time CDI position.

Q:  What should someone who is interested in becoming a CDI specialist do to begin their career? 

JL:  I’d recommend they read The Clinical Documentation Improvement Specialist’s Handbook, too, or check out the ACDIS website before making the leap.  I would also encourage them to get approval to shadow current CDI specialists.

To take the CDI career path, the individual should be very attentive to detail, e computer savvy, and possess clinical expertise. To take on this career, the individual will be required to communicate effectively to everyone from coders to physicians.  I’d also tell them to be honest with themselves regarding their weakness and strengths.  If the CDI role plays up your strengths—go for it!  I wish you the best of luck!  Give yourself time to master this role, however.  It will take months before you will feel truly competent.  One more thing, you will make mistakes.  No one in this field is perfect.

JG: Definitely research the CDI role first. And take part in ACDIS/AHIMA educational opportunities. In fact, join ACDIS/AHIMA on either the national or local level for educational and networking opportunities. Attend conferences/educational programs such as Boot Camps and look for an entry level position with a facility that will help train you.

Of course someone looking to advance their CDI career should be able to research best practices to improve current processes, know how to monitor effectiveness via internal audit/productivity measures, understand the importance of developing policies and procedures. There are other ways to advance your career, too. Those on the cutting edge of this profession know how to develop ICD-10 compliant queries or have become involved in their local ACDIS chapter.

Additional opportunities exist down some unexpected avenues such as CDI travel assignments and remote CDI at home, etc.

Q:  If a CDI professional has been working in the field for a few years what steps should they take to advance their role, program, and/or career? 

JL: Don’t let yourself stagnate.  Always be reading something or pursuing something for your professional growth.  Don’t rely solely on your employer to sign you up for conferences, classes, etc.  Take the initiative yourself and your employer will take notice. Also, if you are interested in an opportunity for advancement—speak up! Your boss can’t read your mind. Once you’ve shared your interest, your boss then starts ‘grooming you’ for the next big thing. You never know!

JG:  Develop a CDI team leader/coordinator position and consider yearly salary market adjustments in addition to raises. Look for reimbursement for conference attendance and tie that attendance to team education and CDI program process improvements. There are increasingly opportunities in collaborative environment and autonomous practice

Q: What steps can a CDI manager take to help staff members feel there are opportunities for advancement at their own facility? 

JL: One thought is to implement a CDI career ladder program.  Another thought is to encourage the employees to build relationships with quality, HIM, case management, and other related departments within the facility as opportunities for advancement may exist and/or open up in one of them.  The specialized experience of a CDI professional along with the other skills one possesses would make for an appropriate transition during a needed time of new projects, etc.

 JG: As mentioned earlier managers need to provide different educational opportunities and tie those opportunities to overall process improvements within the program. Empowering staff to take ownership of their own career is also important.

Q: What are you looking forward to most at this year’s ACDIS conference? 

JL: I look forward to seeing the beautiful city of San Diego, those familiar smiling faces, and taking away at least one pearl of wisdom that will take me to the next level of CDI expertise.

JG:  Presenting about career ladders! I am also looking forward to all the networking opportunities the great educational opportunities. Our local chapter the Michigan ACDIS is having dinner together on Wednesday night and then Friday I’m looking forward to the great Local Chapter Networking Lunch and Event. Of course, I’m looking forward to the sunshine and visiting the Pacific Ocean.

Q: What inspired you to become an ACDIS conference speaker? 

JL: I felt compelled to share valuable insight from my recent CDI career change with my ACDIS colleagues.  I wanted others who may be considering a CDI job change to be even more equipped and informed than I was during my job search.

JG: I am very passionate about creating a career ladder for nurses in alternative practices, such as CDI.  Historically, clinical ladders have been developed for bedside nurses.  The development of the specialty ladder at Northern Michigan Regional Hospital was innovative and based on original literature search, and it has afforded all NMRH nurses equity and opportunity for professional advancement.

Crossing CDI program boundaries

What will it take to push your program beyond its artificial boundaries?

What new boundaries are CDI professionals exploring? CDI specialists discussed several areas of expansion during the 2011 CDI Week celebrations last September. You can read about them in the special CDI Week Q&As and in the CDI Week Industry Survey, which are still available on the ACDIS website. CDI professionals also frequently explore the boundaries of the CDI profession on the ACDIS Blog and on CDI Talk discussion strings.

And I know that those fortunate enough to attend the ACDIS conference in San Diego next week will certainly learn about new documentation improvement opportunities. Come to think of it, the conference has such good ideas every year—and a good idea doesn’t truly get stale—you should take a look back at conference materials from previous events to see what tips you may find and consider implementing.

Conversations regarding CDI expansion really should be considered aspects of program and organizational strategic planning. CDI managers need to consider where CDI specialists will focus their primary efforts over the next year, two years, even five years.

Yes, the regulatory environment governing healthcare is always changing and most CDI program directors can guess about how those regulatory changes will affect CDI, patient care, and the healthcare revenue cycle. But well-informed professionals can make some practical suggestions to position their CDI team appropriately for the future.

Warning, what follows is somewhat like throwing pasta against a wall—some ideas may simply fall and other ideas, like a good al dente macaroni will stick. Regardless, here are my thoughts about possible avenues for CDI program expansion.

CDI specialists should consider conducting record reviews for:

• Mortality/quality/length of stay/severity of illness profiling
• Surgical complications
• Hospital acquired and present on admission conditions
• Medical necessity support (both initial and ongoing stay)
• Evaluation and management documentation

Additionally, CDI programs may gain ground by exploring:

• Medicaid, third-party, private payer initiatives
• Outpatient CDI (e.g., emergency department, ambulatory, denials management)
• Documentation improvement opportunities in alternative settings such as long-term care, rehabilitation, psych, pediatric, and obstetrics units (ACDIS recently launched a new networking group dubbed APDIS-the Association for Pediatric Documentation Improvement Specialists)
• New government initiatives such as Value-Based Purchasing, Accountable Care Organizations, and payment bundling
• Proactive Recovery Auditor and external auditor defense
• Collaboration in development of clinical best practice, documentation, protocols, etc.
• Data mining and reporting (internal drivers and external reports)
• ‘Hardwire’ documentation improvement elements in EMR and IT systems
• Quality data versus coded data
• Why and where does a difference exist?
• What can be done to ensure both data sets are parallel and completely accurate?
• How can CDI contribute to clinical care and quality data measurements?

Of course, a number of previous posts directly or indirectly address exploring new CDI areas. As you investigate new ideas, try new things out, consider sharing with your professional colleagues—comment on CDI Talk, write a blog post, contribute a CDI Strategies quick note, or partner with other staff to write a CDI Journal article.

Diagnose first, admit second

Consider CDI collaboration with case management to target documentation concerns in the emergency department.

Among other tidbits in my background, I’m a recovering case manager.  It’s a hard, often thankless job, and it never ends.  I don’t think I could do it again, and I give lots of credit to those who still work in this field.  Nevertheless, I have had many occasions to interact with case managers in my previous role as a CDI specialist, and now, a CDI consultant.

As a recovering case manager, I often shied away from dealing with the CM department, but I’ve come to realize that not developing collaborative processes can be a huge mistake. When we avoid case management, we avoid the opportunity to build an ally. We both want medical records that reflect the optimum patient acuity, and that will survive RAC and other audits. And this process starts at the hospital’s front door.

Case managers review patients in the emergency department for admission criteria. If they know that chest pain and syncope and abdominal pain are RAC targets, and that documentation of diagnoses instead of symptoms may move the DRG out of the RAC crosshairs, they can communicate this to the physicians. I like to think of it this way: when the physician writes nothing of consequence, the CDI specialist looks for clinical findings and asks for the diagnosis, while the case manager asks for clinical findings and the treatment plan that support the medical necessity for the admission and strengthen the diagnosis that we just got.

It’s a symbiotic relationship.

I’ve had occasion to work with the case management team at a client hospital, and we decided to put our collective heads together to see how we could educate ED physicians not to admit patients who didn’t meet criteria. We chose as our slogan:  “Diagnose first, admit second!”

We created one page flyers to be posted in the ED and distributed to the ED physicians on popular topics such as chest pain and syncope.  In the flyers, we briefly gave suggestions of alternative diagnoses, defined what is needed to meet admission criteria, and encouraged physicians to consult with case management before writing that admit order.

At the same time, I’ve been presenting a weekly series of lectures to the case management department, very similar to what I would use to teach a new CDI specialist, but adding a little twist that ties clinical documentation improvement to case management.  It’s been a big hit.  They are eager to help teach physicians not to write “CHF” or “urosepsis,” and they want to learn more.  I’m going to give them all they can handle, including helping them read their PEPPER and use it to their best advantage.

Never assume that because someone doesn’t understand what you do, that they don’t want to understand what you do.  It’s like working with physicians and nurses; when you show them how your job relates to them and how it benefits everyone, you get more cooperation.  And as we used to say, cooperate and graduate.

CDI staff play an important role in the transition to electronic health record

Don't let the transition to electronic records become speed bumps to your CDI program efforts.

As I was waiting in the security screening line in an airport recently, I overheard two women speaking together regarding the need to give up their cellphones to the x-ray machine.  One commented, “I can’t give up my phone.  It’s my life and I can’t imagine what would happen if I lost it or if its contents were erased.”

The conversation seemed like a classic illustration of our dependence on technology. Yet just a few years ago many of us proudly stated that we would “never become dependent” upon these devices.

I personally remember stating that I’d NEVER join the texting world and yet here I am not only texting my family, but colleagues, and clients as well.  I’ve witnessed many a nurse “text” a message to a physician.  These same physicians are now being asked to complete orders electronically and many are beginning required to document care via an electronic medical record (EMR).

So what are the effects of EMR’s on the world of clinical documentation improvement?  Well, it certainly hasn’t erased the need for clarification of documentation.  It may actually create more queries than it eliminates. Legibility may have improved but identification of conditions being monitored and treated is still often lacking in clinical documentation. The way physicians assess and treat patients haven’t changed, the only thing different is how their thoughts are captured in the medical record.

Physicians who have always provided a detail-less “story” of the admission will still need to be queried to identify the conditions they are caring for during the admission. Drop downs and templates designed to make documenting easier for physicians, often create confusion and misrepresentation of patient conditions so this too will result in the need for clarification.

CDI specialists continue to be a primary resource for physicians, providing education regarding appropriate and compliant documentation. This is particularly true when supporting documentation within an EMR.

Therefore, CDI specialists need to have a thorough working knowledge of the electronic program being used for physician documentation so they can provide support to physicians. Supporting appropriate use of possible drop down choices or checklists ensures that accurate documentation of the patients’ severity of illness is captured in the record. Often CDI specialists participate in the nursing portion of EMR training but it is equally important for them to understand the provider applications so they can help train and guide physicians through use of the program.

Electronic queries pose their own unique issues as well.  In 2009, Barbara Hinkle-Azzara, RHIA, VP of Operations for Meta Health, in New York City, identified 10 tips that support use of electronic queries to streamline the query process and provision of a direct link to the EMR.  She points out some key reasons that support the use of electronic queries but it is important to ensure that the proper education is made available to providers so they use the system correctly.

Monitoring physician response rates before and after transition to an electronic system will assist in identification of possible process issues including the possibility that physicians are not addressing queries because they don’t know where to find them in the EMR.

Clearly due to the need to move to the EMR, electronic queries will become the “new” method of clarifying documentation issues with physicians. CDI specialists should not fear the move to EMR’s as even the most sophisticated EMR is not likely to eliminate the need for the CDI specialist role in serving as a “documentation resource” to healthcare providers.

However, it is important that CDI specialists are prepared to serve as a resource to physicians and are adequately educated regarding the proper use of the EMR program and the electronic query process.

CDI ‘Roadmap’ committee charts program priorities

Don't get lost on the road to success. The CDI Roadmap Committee will offer direction for new programs.

Although you might not have heard of it before, ACDIS has formed a group called the CDI Roadmap Committee to help develop and define some of the core structures that the CDI profession has been lacking. These include the broad goals and objectives of CDI, staffing and productivity considerations, setting new goals for mature programs, and a realistic structured outline to help map out the way.

The CDI Roadmap Committee has been meeting since September 2011. The committee currently consists of the following members:

• Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, ACDIS Advisory Board Member, Independent Revenue Cycle Consultant in Madison, WI.
• Lynne Spryszak, RN, CCDS, CPC-A, ACDIS Advisory Board Member and independent HIM consultant in Roselle, IL.
• Donna D. Wilson, RHIA, CCS, CCDS, ACDIS Advisory Board Member and Senior Director of Compliance Concepts, Inc. in Wexford, PA.
• Cheryl Ericson, MS, RN, ACDIS Advisory Board Member and CDI manager for Medical University of South in Charleston, SC.
• Gail B. Marini, RN, MM, CCS, LNC, ACDIS Advisory Board Member and CDI manager for South Shore Hospital in Weymouth, MA.
• Beth Kennedy, RN, BS, CCS, CCDS, Associate Director, Documentation Improvement Program CMO, The Care Management Company, LLC., Montefiore Medical Center in Bronx, NY.

The majority of the group’s first meeting was spent discussing the purpose and intent of the group and defining both short and long-term objectives. The committee determined that its objective is to create a phased approach to CDI success. The team decided to develop a pre-implementation timeline/checklist, then took a deeper delve into the goals/objectives of a basic CDI program and requirements and expectations for staff.

At subsequent meetings members offered drafts of a pre- implementation checklist with items such as assembling a steering committee and an outline for developing a project plan. The group also discussed sample orientation checklists, collected job descriptions for physician advisors, CDI supervisors, and CDI specialists, and discussed potential CDI evaluation criteria and assessment of CDI staff coding and clinical skills.

The CDI Roadmap Committee will likely break after it completes the “pre-implementation” and “implementation” phases of the timeline, and continue work on “ongoing maintenance” and “advanced level CDI” phases at a later date.

The committee plans to send its work to the ACDIS advisory board for approval and compile its findings in a series of White Papers available as free resources to the ACDIS membership.

Editor’s Note: This article first appeared in the March 15 edition of CDI Strategies.

Will CDI staff take on larger role in querying physicians?

More CDI reviewers could be needed once ICD-10 implementation occurs. Will facilities be able to look past the simple CC/MCC, financial incentives for reviews?

By Shannon E. McCall

Physician queries are considered communications between coding (or coding-related) professionals and physicians to clarify or increase specificity in the documentation to ensure good clinical documentation as well as to support code assignment for the billing process. Queries are technically not limited just to inpatient coding and in some cases can also be done for outpatient or professional services. For the moment, I’d like to focus more on the previous than the latter.

Currently, queries can be performed concurrently or retrospectively to the inpatient admission/discharge. Concurrent queries, which are generally preferred, are posed while the patient is still “in-house” and the physician is readily available to provide clarification while the information is new in his or her mind. Verbal queries are generally included with the concurrent queries. Retrospective queries are performed after the patient is discharged, typically prior to the billing or post-billing. The query responsibility is generally shared by the coding staff as well as clinical documentation improvement (CDI) staff members.

Now on to why I am bringing this up.

Queries performed by CDI specialists traditionally have been mostly limited to diagnoses (and in many cases ones that affect the overall reimbursement), such as complications/comorbidities (CCs and MCCs). But some of these queries have no financial bearing on the case and are simply posed to obtain added specificity to reflect true severity of illness.

We know that with all the added details in the ICD-10-CM diagnosis codes, there very well may be many more opportunities for queries to be posed. But, my cause for concern is that the ICD-10-PCS codes will require a very thorough understanding of how physicians actually perform the procedures and the anatomy involved, which may go beyond the clinical knowledge of coder.

So, will CDI specialists become more involved in the query process as it relates to procedure coding? Procedures can certainly have an impact on the overall MS-DRG assigned, and incorrect assignment can lead to improper overpayments (or underpayments). If a question arises regarding a procedure, would it make more sense for the coder or the CDI specialist to pose it to the surgeon? CDIs are in many cases spread very thin (as coders are as well) and may even find it hard to even touch all the cases more than once or twice from a diagnosis standpoint.

So will it present problems in the future if we add to their workload additional clarifications needed for operative reports? All seven characters must be assigned to qualify as a complete ICD-10-PCS code, so there is no way out by using a vague code with digits/characters identifying “unspecified.”

Editor’s Note: Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, is director of coding and HIM at HCPro, Inc. Shannon serves as the director over the Certified Coder Boot Camp ® programs. Contact her at smcall@hcpro.com. This post was originally published on the ICD-10 Trainer Blog on February 22.

Words to clarify by

Use these common phrases as clues for further investigation.

Many novice CDI specialists do not readily identify when a diagnosis needs clarification. The following list is intended to serve a gentle reminder to “dig deeper.” Here is a list of “clue” words to help you identify when a query may be needed for clarification or specificity.

AMS needs clarification as to possible Acute Confusional State, Alzheimer’s Dementia, or Alzheimer’s with Behavioral Disturbance. If with associated Infection, metabolic condition, etc. it could also indicate Encephalopathy.

Urosepsis could be UTI or Sepsis secondary to UTI.

Hypoxemia/Respiratory Insufficiency could indicate a diagnosis of Acute Respiratory Failure or Acute post Operative Respiratory Insufficiency if the indicators are present. (E.g. Use of C-pap or Non re-breather mask, or O2 saturation less than 92%).

Anemia requires specificity of Chronic Anemia, Acute Blood Loss Anemia, Aplastic Anemia, etc.

Renal insufficiency/chronic kidney disease (CKD) requires added specificity for the stage of the CKD, the Creatinine baseline and further specificity as to possible Acute Renal Failure (ARF), and if indicators present (E.g. nephrotoxic medication usage) ARF with Tubular Necrosis.

FTT, Anorexia may indicate Malnutrition. If present, further specify as to whether it is mild, moderate, or severe.

CHF requires specificity of acute or chronic and systolic or diastolic heart failure.

Right/left sided weakness may indicate a diagnosis of hemiplegia or hemiparesis.

Problems with speech post CVA may indicate a diagnosis of Aphasia.

Drug use History requires clarification of use or abuse and if the Drug Use/Abuse is Ongoing.

Abdominal pain requires documentation of an underlying diagnosis. (E.g. Ulcer, Acute Pancreatitis, etc)

Chest pain requires documentation of an underlying diagnosis. (E.g. CAD, Angina, Costochondritis, etc.)

Gangrene-requires further specificity as to “Wet” infectious or “Dry” ischemic Gangrene

Poorly controlled Diabetes needs clarification whether Uncontrolled or Controlled Diabetes Mellitus.

Hypertensive Emergency needs clarification as to Malignant or Accelerated Hypertension.

DVT needs clarification as to Deep Vein Thrombosis or Thrombophelbitis.

I&D needs clarification as to whether this means Irrigation and Drainage, Exisional Debridement or Non Exisional debridement. (If exisional debridement performed then documentation must state if scalpel was used, clear margins obtained, and depth up to and including deepest layer.)

↓↑Na is not a diagnosis. Documentation must be obtained as to possible Hyper/ Hyponatremia.

CDI specialist orientation (more CDI Talk inspiration)

One of the repeated conversation themes on CDI Talk is how to orient a new staff member (within an existing program), or how a small program can start its own CDI efforts and train its own staff. Parallel to those conversation threads are participants’ real hunger for more avenues and sources of education.

Let’s look at some of ACDIS’ online poll data to set the stage:

• July 2011: How many total years of professional experience do you have in healthcare (CDI, plus other)?
• 20 years or more, 60%
• November 2009: How long did it take you to get up to speed as a new CDI specialist?
• 3 to 6 months, 32%
• 6 to 12 months, 34%
• June 2011: How long do you think it takes to achieve an “expert” level of proficiency as a CDI specialist?
• 2 years, 35%
• 3 years, 22%.

And here’s one  final on-line poll data point to help me answer the question as to whether CDI managers are actually providing enough training to new staff members:

• January 2011: How long is your training period for new CDI specialists?
• 12%, 2 weeks
• 22%, 30 days
• 30%, 31 to 60 days
• 20%, 61 to 120 days
• 12%, approximately 6 months
• 3%, less than 6 months

It seems to me that those who indicated that it takes six months or more to get up to speed need more training than what I commonly consider necessary as part of orientation.  This data suggests that what is these new CDI specialists need is more of a mini-college training program.

Obviously there is a rather significant challenge—how to provide the level of knowledge and training along with the

(Image via Homeclick) It is a sink that is made so fish swim in it. Get it? Sink or swim.

appropriate mentoring to actively promote and support the new CDI specialists so they can succeed. Of course, there is always the consultant option which proves to be relatively expensive. Plus, a ‘mature’ program should not need to rely on such an expensive option for new staff orientations. At the opposite end of the spectrum is the ‘sink or swim’ method.

Thankfully, home grown and self-supported possibilities exist to constitute a middle ground between these two options. At the very least, facilities should implement an orientation or mentoring process where the experienced individual’s guidance can make a huge impact.

I believe the biggest challenge facing those hoping to implement a CDI orientation program comes from a lack of targeted, written learning resources. I consider one of the largest draws for ACDIS membership stems from the need for learning, resources, and accessibility to a community of knowledgeable and supportive peers. ACDIS provides such a community, with a quickly growing resource base. (If you’re a member, you ought to know. If not, go look at every part of the ACDIS home page).

In addition, ACDIS offers a few helpful handbooks and guides that can be re-purposed for orientation, such as:

• The 2012 CDI Pocket Guide
• The CCDS Exam Study Guide
• The CDI Specialists Handbook, second edition
• The Physician Queries Handbook

Furthermore, the only independent (i.e., not part of a consulting package) seminar I’ve found is HCPro’s CDI Boot Camp. While the total cost (fee, travel, hotel) may be prohibitive for many there is also the online version as an option. Again, a mature CDI program ought to be able to handle at least some of the orientation process internally.

Even with the valuable resources of ACDIS, some holes in new staff orientation remain. AHIMA and AHA’s Coding Clinic for ICD-9-CM provide further guidance, but even those resources do not cover everything. Several major elements of an orientation program are not addressed by the resources mentioned.  Just to get started, how about:

• Creating a tool that outlines in detail basic competency and knowledge expectations for the novice CDI specialist. This tool should also list areas for mid-level and advanced achievements to give new CDI staff a set of expectations for continued professional growth. There are some examples in the Forms & Tools Library, in the policies and procedures section (search for “staff orientation checklist), but not at the detail I envision.
• Curating a collection of vital subject articles and references. (Review the CDI Journal archives, the ACDIS Blog, and the Helpful Resources links just to get started on this collection. Add in other professional organizations and their publications such as the National Institutes of Health, AHIMA, AMA, and others and this would be a one-stop database of useful CDI knowledge.)
• Creating an outline of topics that the new CDI specialist needs to master before achieving their initial competency. Further, this outline ought to provide enough detail and referenced sources to serve as a complete training program guide.
• Sources would likely include the books and articles mentioned immediately above, along with sections of widely accepted texts such as coding guidelines, Faye Brown, and medicine texts like the Merck Manual.

Before starting to collect all those articles and tools, though, I should probably determine the basic elements of an orientation program! Below I’ve listed a few resources online which discuss this, including:

• The five key elements of a good orientation program
• The Community Tool Box: Developing Staff Orientation Programs
• Making New Employee Orientation a Success

After reviewing these, I must confess that my definition of orientation varies from those discussed above.  Still, several points are important to keep in mind to successfully bring a new staff member up to speed in the CDI world:

• Provide structured, purposeful training
• Offer a straightforward sequence of topics or activities to enable learning
• Give new staff members a written agenda complete with goals and measurable objectives
• Provide ongoing, two-way feedback and evaluation
• Supply appropriate resources and support
• Actively integrate the new person into the team
• Celebrate and welcome the individual and his/her accomplishments as they gain proficiency in their new role
• Pair new staff with an experienced mentor and provide oversight of their engagement
• Offer engaging, interactive, as well as some self-directed education

However, as mature and professional learners, CDI specialists must be responsible and accountable for their education and success.

Honestly, for a new or developing program that has to add or replace staff, the right consultant is worth the money.

At some point CDI programs need to be able to hire new staff and train them in-house. Creating a comprehensive training program does require a lot of effort and maybe it is work that some of you have already done?  If so, why duplicate work? Let’s see if we can compile a  “best of” list of what program components others have found successful and create a tool that we can share. Post your information here to the blog, e-mail me, or contact Associate Director Melissa Varnavas mvarnavas@cdiassociation.com

Q&A: Resolving the case load, productivity question

We love to respond to your questions. Post yours in the comment section below.

Q: For a newly trained CDI specialist, what is the approximate number of reviews (both concurrent and follow up) one should expect him/her to be able to handle per day? I recall from the CDI Boot Camp that the starting number was about 10, but I can’t remember how many new versus follow-up cases CDI staff should expect to review. I assume that the base number of 10 records increases as the weeks goes on, right?

A: From my experience, a newly hatched CDI specialist working solo should be able to review about 10 cases/day for the first few weeks. I typically give a new person just one unit to cover, which would mean that on Monday she/he would have about 5-10 new admissions from the weekend (depending on the size of the unit –for example, our units were about 20 beds each) plus their re-reviews. Thereafter that person could have two or three new admits per day which would make about 10 or so total reviews.

After a month, I would add a second unit, thereby doubling the reviews from 10 to 20. A full assignment for my reviewers was four units. I tried to give people similar clinical units to cover so there might be some overlap. For example, whoever covered the cardiovascular intensive care unit (CVICU) would also cover the post-coronary artery bypass graft (CABG) units. That way,

if she didn’t get to review the CVICU record that patient would eventually be hers in the CABG unit and she could review the case then.

As the manager I really scrutinized the number of admissions on each unit (from a data perspective) so that everyone’s assignments were about equal and that everyone had similar query-opportunity units. This way the CDI specialist could not only learn different areas and become more professionally versatile for the benefit of the hospital but enable him/her to build additional physician relationships and a broader understanding of conditions based on the range of physician perspective.

At the six-month mark a CDI specialist would assume a full assignment. Again, as a manager, I understood that it would still be a while before he/she was able to identify documentation improvement opportunities with 100% ability. Our program had processes for prioritizing reviews as well as clearly defined query follow-up policies. Our physician response rate goal was 100% and our policies and processes were designed to make that happen.

My team only had documentation responsibilities, however. We did not perform utilization review, case management, or other measures. If these additional tasks are added to a CDI specialist’s to-do list, I would recommend you adjust your program’s expectations accordingly.

If you have utilization review tasks also included in your CDI duties, and find it inhibiting your ability to follow-up on outstanding CDI reviews, track the number of cases that you are unable to review or follow up on for one-to-three months. This ensures you have data to support your position—that the additional role of utilization review hampers your ability to effectively complete CDI reviews of the records.

Your data should also show potential lost opportunities such as reductions in captured severity of illness/risk of mortality scores, DRG change, missed queries, etc. so that you can show how the lack of complete record review negatively affects the facility and patient care.

Editor’s Note: This article first appeared in the February 16 edition of CDI Strategies. For additional information regarding productivity metric for CDI specialists see also:

• Survey: Production expectations for reviews, re-reviews
• CDI Productivity Benchmarks (A CDI Talk topic)
• Q&A: Productivity measures for CDI specialists
• Additional thoughts on CDI staff productivity
• Metrics ideas and thoughts
• Q&A: Maintaining CDI productivity under the SOI/ROM system
• Chart reviews: Best practices from three perspectives

Reflections on physician leadership and engagement with CDI programs

Over the past several years there have been a number of conversations that touch on physician leadership involvement with CDI. Programs can and do achieve success, but so much more is achieved when there is a proactive and supportive medical voice.

Physician leadership can come from a number of sources and in a variety of forms. Some CDI programs (a few anyway) report directly or indirectly to a physician executive (medical staff functions, chief medical officer [CMO], etc.) and other programs report to the quality department where a physician executive is frequently directly involved. In these circumstances, I hope the physician executive maintains some amount of time dedicated for CDI efforts.

Some organizations are fortunate enough to have physician leadership within the broader organization that is (or have been convinced to be) very supportive to CDI efforts. From what I’ve heard, these frequently include CMOs and chiefs of staff and/or service lines within a given facility. Finally, some physicians, such as a medical director, physician champion, advisor, or liaison, devote a portion of their time to work directly with CDI. (Read more about the expanding roles and responsibilities of CDI physician advisors in the January 2012 edition of the CDI Journal.)

Furthermore, even with supportive medical staff leadership, how that support translates into action varies. Some facilities provide physicians time to offer educational sessions to their CDI and coding teams. Others provide CDI education sessions to entire physician groups by service line.

Most CDI programs earn physician leadership and support through the tireless efforts of the CDI staff and program leaders. Only occasionally have I seen this support present from the very beginning.

Some Perspectives

I’d like to look at the “state of affairs” in regards to physician leadership.  One ACDIS weekly online poll (2008) addressed the simple question of whether respondents had a “physician champion” and if that champion was effective. That poll was rather surprising; only 46% indicated they had a physician champion, and half of the respondents with a physician champion actually rated him/her as ineffective. So, according to that poll, only 23% of programs have an effective physician advisor.

ACDIS repeated the  poll (with slightly different wording) in April 2011 and though the results showed some improvement, they were still discouraging. In 2011, 31% described having a very beneficial physician champion, 22% described their physician champion as “’minimally effective”, 24% felt the position was not affordable, and 16% indicated that their program could not find a good candidate. Even more surprisingly to me, 7% said they simply did not see the need for the roll.

Additional polls from 2008 which echo the theme of limited physician support for CDI programs include:

• “How have physicians reacted to your CDI program and query requests?” where only 40% reported a positive response from physicians
• “Are your physicians catching on to your CDI program? ” 3% yes, 74% yes and no, 23% no
• “Do you have any physicians who refuse to participate in your CDI program?” where 81% indicated anywhere from one to many physicians refuse

Other recent poll responses illustrate different aspects of physician involvement in CDI , but I thought these painted an interesting picture.

Don’t forget the most recent study, published in the January CDI Journal, in which 73% (178 individuals) indicated that their physician advisor spends five hours or less dedicated to CDI efforts, and 54% described their advisor as either moderately effective or ineffective.

Data

I think it is  important to have data to effectively measure any focus area of interest. I believe a couple of key metric data pieces provide insight to the level of success with physician engagement. In any analysis, I would include items such as:

• Physician response rates
• Severity of illness (SOI)/risk of mortality (ROM) data
• Trends in volume of queries and more specifically the focus of queries (Do CDI staff ask the same queries repeatedly?)

I specifically would not include physician agreement rate except in a broader sense in looking for individual outlier physicians, to find those who either agree to whatever the CDI specialist asks or those who never agree with the premise of a CDI specialist’s query.

As always, I’d love to hear what elements other CDI programs use to statistically validate their physicians’ involvement with and support of their CDI programs.

Resources

Quite a bit of material is available between the ACDIS online polls (I have fun with those, obviously), various blog postings, journal articles, and conference presentations that offer useful information regarding physician engagement. Several provide inspiring examples of successes. Various items from other organizations are in the public domain.

If you are interested, shoot me an e-mail or leave a comment here and I can develop a partial list of links.

Wrap -up

I am sure most agree that fostering physician engagement in CDI efforts is one of the key challenges of every CDI program.

I certainly don’t have many great answers to this question, and I’d like to hear more thoughts, experiences, and success stories. I know some great examples would be wonderful Journal articles or blog posts.

I will toss in a final thought. Organizational cultural change typically takes five years. Certainly obtaining physician interest in documentation and coded data represents a significant cultural change.

Sometimes I wonder if just need to practice a little more persistence and a lot more patience.