Finding a definition for failed CDI programs

How can a CDI program find success without a proper defination of what it means to fail?

In March, I started a conversation on CDI Talk entitled “Failed Programs,” hoping at the time that there might be someone willing to divulge a first-hand account of how and why their program “failed” and perhaps how they were able to “save” or “reinvent” it. I was hoping to gather enough information develop an article on the topic for the CDI Journal.

While the title of the discussion generated quite a bit of conversation (there were upwards of 36 responses at the time), no volunteers came forward. Unfortunately (or maybe fortunately), I don’t have any first-hand experiences with a “failed”, nor do I have any personal reflections to share from direct colleagues. Furthermore, the online discussion on CDI Talk helped me realize there is not a clear definition for what might be considered a “failed program” in the first place.

I understand this is a very sensitive subject. There might be real reluctance to participate in such a discussion depending on an individual’s experiences. Revealing serious struggles might risk erroneous implications about a present program and not some previous or anecdotal one. In my (humble) opinion, however, recognizing program problems can help us seize a genuine “opportunity for improvement.” (I’m not a fan of that phrase, by the way, thus the quotes. Am I the only one who dislikes it?)

But maybe even better than an individual program finding potential success amidst the rubble of seemingly insurmountable obstacles is the possibility that together we can all learn something from each others’ schools of hard knocks.

So, I request input (100% private and confidential) from anyone who might be willing to share their experiences of a CDI program that has either failed or come close. With some good input from our professional community, I believe there will be enough information to provide an article with some great insights into pitfalls and risks, strategies for success, and methods to rebuild.

For now, let’s focus this conversation around the variations of “failed” programs and think about potential underlying causes. Before we can consider failures, maybe we should outline what the industry has come to view as CDI program standards and basic functions. To help provide a framework for my reflections, please review these two quotes from the AHIMA Guidance for Clinical Documentation Improvement Programs (May 2010):

“The focus of most CDI programs is on improving the quality of clinical documentation regardless of its impact on revenue. Arguably, the most vital role of a CDI program is facilitating an accurate representation of healthcare services through complete and accurate reporting of diagnoses and procedures.”

And:

“A successful CDI program can have an impact on CMS quality measures, present-on-admission conditions, pay-for-performance, value-based purchasing. The documentation in the medical record becomes data that is used for decision making in healthcare reform, and other national reporting initiatives. Improving the accuracy of clinical documentation can reduce compliance risks, minimize a healthcare facility’s vulnerability during external audits, and provide insight into legal quality of care issues. In a successful program, the CDI professional works to facilitate the overall quality and completeness of clinical documentation to accurately represent the severity, acuity, and risk of mortality profile of the patient being treated.”

I also encourage review of the ACDIS White Paper “What Every CDI Program Needs to Succeed is Structure, Staff, Process,” by Lynne Spryszak, RN, CPC-A, CCDS, CDI education director for HCPro, Inc., in Danvers, MA.

So, without further ado, here are some thoughts I had on defining “failed” or “under-performing” CDI programs.

A “failed” program is one which:

• Completely ceases to exist due to:
  • Elimination or cancellation by the organization either as a cost saving measure or perceived/actual lack of performance of the program.
  • Staff departures, which prevent long-term viability/sustainability. This might reflect a program where success is based on individual performance rather than on the CDI process. Also, smaller programs are likely at higher risk where the loss of one or two team members can eliminate the program’s ‘institutional memory.’
  • Some fault or error surrounding initial implementation, program design, or inadequate support.
  • Lack of sufficient staffing where the devoted resources are inadequate or not supported.

• Significantly misses performance targets (or metrics) where
  • Targets are undefined and/or internal benchmarks are not established
  • Metrics are not rigorously reviewed for accuracy, shared, and/or applied to maintain focus and potential growth
  • Targets are unrealistic (may be either internally set or established by consultants)
  • Metrics are focused primarily on financial impact
  • Metrics are appropriate but goals and findings are not shared with CDI specialists
  • Benchmarks and reporting are efficient but findings are not used as tools for CDI staff or physician education and feedback

• Cannot withstand audit scrutiny such as:
  • Whistleblower suits similar to those discussed at the 2011 ACDIS conference by Jamie Bennett Assistant U.S. Attorney from District of Maryland.
  • RAC, MAC, MIC, CERT reviews

• Eliminates or transfers staff due to a perceived lack of success or financial hardships
• Lack of medical staff engagement, collaboration, and support due to:
  • Ineffective communication of the CDI program mission
  • Lack of administrative support that encourages medical staff partnership in the CDI program.
  • Uncooperative medical staff/organizational relationship

• Has been deemed to have failed by an external (consulting) group due to:
  • Analysis of performance, metrics, or focus (based on the consultant’s standards); the program from the consultant’s perspective doesn’t measure up
  • A change in consulting relationships from one firm to another, especially where there are differing philosophies and goals
  • A change in CDI program focus

Of course, there are those programs which have not “failed” but which we may consider less than successful. What are the indicators to watch for in those cases? In my opinion, a less-than-successful CDI program is one that:

• Exhibits continuous staff turnover and/or is chronically understaffed due to
  • Inappropriate training
  • Insufficient employee screening, interviewing, and assessment
  • Inadequate administrative and executive support

• By design, focuses only on one area of CDI activity, which results in lack of improvement in other (ignored) areas. For example:
  • Preventing or refuting RAC denials (as would be seen with an effective multi-spectrum CDI program)
  • Facility and physician profiling data and reports (such as risk of mortality, length of stay, PEPPER report, core measures, etc.)

• Executives and/or organizational leaders express dissatisfaction due to:
  • Lack of appropriate leadership education and effective reporting of program successes
  • Ineffective CDI leadership/management
  • Unsatisfactory attempts to “win over” facility leadership

• Lacks involvement with other organizational projects and initiatives or preparatory efforts such as:
  • The development and revision of various clinical and medical record forms 
    • Such as skin and wound assessment, wound treatment, ‘fill in the blank’ style procedure forms, specialty consults, See January 2011 CDI Journal article written by Trey La Charite, MD, “Prevent RAC denials: Improve excisional debridement documentation”)
  • Development, implementation, and ongoing integration of electronic medical records
  • Review of records for quality concerns
  • Review of records for clinical best practices
  • Review and analysis of financial forecasts and CDI program impact (with particular focus on impacts of coding and documentation changes)
  • Physician education (including residents)
  • ICD-10 planning and preparation at the level of steering committee (or other major changes).
  • Value Based Purchasing

• Exhibits interdepartmental hostilities between CDI and HIM due to lack of
  • Clearly defined roles and responsibilities
  • Adequate management interaction
  • Appropriate leadership chain of command
  • Inclusion of various team members in CDI processes
  • Smooth, integrated process flow toward a common goal of accurately coded complete medical record

• Inadequately prepares, pursues, applies, and completes performance improvement activities such as:
  • Benchmarking
  • Metrics
  • Analysis
  • Staff education
  • Focused educational projects (by service, physician group, clinical topic)

Looking back over all these items, it seems like a daunting task to be successful. The program with enough resources to actually meet all of these (let alone do them well) may well be a leader in CDI program best practices.  Maybe I am being a bit too demanding, but it seems to me that just taking one or two items off this list at a time, could generate solid long-term improvements.

I am sure other CDI professionals have other thoughts about what makes a program fail, so send them in. If you think my thoughts here are off-base, or if you think there are obvious things I’ve missed, please let me know—I very much want feedback!

And I’ll repeat: If anyone is willing to confidentially share any direct details about a program or organization that falls into these categories, please contact me privately, at dbutler@pcmh.com or ACDIS Assistant Director Melissa Varnavas at mvarnavas@cdiassociation.com and ask her to forward the information.

Book Excerpt: Take a team approach to ICD-10 planning

The Clinical Documentation Improvement Specialist’s Guide to ICD-10

A best approach to a successful and on-time conversion to ICD-10 is a multifunctional and multidisciplinary team approach; however, you most likely will need to divide and conquer when it comes to specific tasks, so consider forming subgroups or teams to address the different assessments related to compliance with ICD-10.

Consider forming a steering committee with subgroups, as needed, based on the impact analysis. Your organization may already have a standing committee or team that could serve as the ICD-10 transition steering committee, but everyone involved should know that the job is a massive one and time is slipping by quickly. Therefore, however the team is formed, it must be ready for action.

Because this project is so huge, consider using an external or internal consultant as a project manager. Many CDI, HIM, and IT leaders are skilled at project management so each organization will have to decide how to move forward based on its own structure and expertise.

Editor’s Note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Guide to ICD-10.

ACDIS quarterly conference call available for download

Hi ACDIS members,

You can now find a recording of the quarterly conference call of May 26, 2011 on our conference calls page, here.

Also, please note that the powerpoint presentation “Unlocking the Potential” presented during the call was missing two slides (slides 14 and 15) but the presentation has been updated and may also be downloaded on the conference calls page.

Lastly, if you have any feedback on the content and organization of the conference calls, suggestions for improvement, or ideas for future calls, please feel free to leave them here or e-mail me directly.

Thanks a lot,

Brian

Get involved to promote CDI awareness

If you read the latest edition of the CDI Journal you’ll know the CDI professionals’ role is gaining attention even from those who work

Not all scientific studies require a magnifying glass.

outside the healthcare revenue cycle. I’m referring to the study being undertaken by Gary C. David, PhD, associate professor of sociology and associate professor of information design and corporate communication at Bentley University in Waltham, MA. He is essentially researching the roles and responsibilities of CDI staff in an attempt to better understand the sociological and communication nuances required to effectively perform the job. You may have seen him at the 2011 ACDIS Conference in Orlando.

Although he isn’t sure what the final form of his research will be, he believes the study has implications for a number of industries, not just healthcare. David’s already conducted several interviews and plans to conduct several more before he concludes his research. If you want to be involved, contact him at GDAVID@bentley.edu or via his blog http://ehealthrecords.wordpress.com. Don’t worry, this isn’t the type of study that requires you to undergo some weird brain imaging or anything. All it requires is a little bit of your time talking about the CDI profession.

CMS posts new Meaningful Use FAQs

Are you involved in EHR implementation planning?

CMS recently published these questions and answers regarding “meaningful use.” For CDI professionals, that phrase may be unfamiliar and raise some questions: meaningful to whom and meaningful how? Use of what? In layman’s terms “meaningful use” is the bar facilities must reach to prove that their implementation of electronic health records’ (EHR) systems is meaningful, useful, and that the record is workable and capable. CDI specialists probably think these items need not cross their already crammed minds. The EHR implementation belongs in the hands of the IT or HIM department, right?

A few recent conversations, however, had me curious about whether CDI staff or at least those familiar with CDI program efforts shouldn’t have a place at the EHR implementation planning table. One woman mentioned that her facility EHR includes a drop-down menu where physicians choose the principal diagnosis. In theory, she explained, this would be a terrific advancement, but what happens when the physician finds chronic obstructive pulmonary disorder but doesn’t keep searching to identify additional specificity? Essentially, CDI specialists will face the same old challenges under EHR and a host of new ones, she said.

So when I came across this release of FAQs I thought I’d share them here on the blog along with a few questions of my own:

• Is your CDI program involved in EHR implementation planning?
• If so, what are you finding to be your biggest challenges?

Here are the FAQs from CMS:

1. For the meaningful use objective of “capability to exchange key clinical information” for the Medicare and Medicaid EHR Incentive Programs, does exchange of electronic information using physical media, such as USB, CD-ROM, or other formats, meet the measure of this objective? Read the answer.

2.    For the Medicare and Medicaid EHR Incentive Programs, how should an eligible professional (EP) who orders medications infrequently calculate the measure for the “computerized provider order entry (CPOE)” objective if the EP sees patients whose medications are maintained in the medication list by the EP but were not ordered or prescribed by the EP? Read the answer.

3.    How should patients in swing beds be counted in the denominators of meaningful use measures for eligible hospitals and critical access hospitals (CAHs) for the Medicare and Medicaid EHR Incentive Programs? Read the answer.

4.    How should nursery day patients be counted in the denominators of meaningful use measures for eligible hospitals and CAHs for the Medicare and Medicaid EHR Incentive Programs? Read the answer.

5.    What lab tests should be included in the denominator of the measure for the “incorporate clinical lab-test results” objective under the Medicare and Medicaid EHR Incentive Programs? Read the answer.

For more information about meaningful use and its requirements, take a look at the Meaningful Use page or visit the CMS EHR Incentive Programs website.

The CDI evolution

By Juanita B. Seel RN, CCDS

I have been a CDI specialist for seven years. I wanted to share with all of you how our program has evolved throughout the years.

Looking for ways to grow your program?

When we first started our program in 2004, it was all about capturing the CCs (there were no MCCs at that time). It focused on moving the DRG to a higher weighted category. Physicians always asked, “How much money will this earn for the hospital?” We were called the “chart police,” “green sheet ladies” (our queries are bright green), and many more things I am sure.

I did not like the fact that we were seen as only trying to get more money for the hospital. To me, my job meant more than that. It was about capturing the true severity of illness of the patient being treated; it was about the most accurate risk of mortality being captured. It was about having the medical record stand on its own without the need to question diagnoses and codes for the record.

Fortunately, a few of the RN CDI specialists I worked with felt the same way. We soon started our own little movement to shift our focus away from DRG capture and to query the physician for any diagnosis not adequately documented in the chart—even if it actually lowered the DRG. We started looking for the consistency of documentation, the clarity of documentation, the correct description of diagnoses and clinical data to support all of these in the medical record.

When MS-DRG’s hit, we became more assured this was the way we wanted our program to be. I changed the way I presented information to physicians and focused more on clear, concise, and accurate documentation. I focused more on “you documented this, but did you really mean this.”

Our CDI department quit singling out queries for diagnoses that would raise the DRG to a higher level. We queried the physician for any diagnoses for which documentation was unclear, vague, or just plain not documented well. Our percentage of queries went from 15% to 35%. Our goal was to have the medical record stand up against any audit or review as far as documentation was concerned. We wanted to make sure the treatment plan matched clinically with the diagnoses in the medical record.

The strange thing was that when we did this, when we concentrated more on the accurate documentation, the money came. Our CMI stabilized (with a healthy fluctuation); our risk of mortality rates stabilized, and our severity of illness clearly indicated the illnesses—both acute and chronic—the patient was treated for. Physicians began to see us in a different light. We could discuss, sometimes at length, why the “coding language was so different from the medical language.”

Our program now has an 85% query response rate. We write an average of 700 queries a month, with an average chart review rate of 2,400 charts per month. We have a staff of five full time RNs, two part-time RNs, and one supervisor. We review charts at the main hospital and two outlying facilities. Our hospital has 700+ beds and the outlying bed total is about 125.

I am very proud of our program and how it has evolved. The point is, if a program will review the record based on the medical documentation matching the coding language needed, teach physicians what is needed in documentation and concentrate on the accurate documentation of all diagnoses in the medical record—not just CCs and MCCs—the money will come naturally, and auditors will not be taking away codes because of documentation issues.

Please feel free to contact me about our program. I love to brag about the work of our CDI specialists.

Editor’s Note: Juanita B. Seel RN, CCDS, is the Documentation Integrity Supervisor at Greenville (SC) Hospital System University Medical Center and current co-leader of the South Carolina ACDIS Chapter. This article was originally published on the DCBA blog “CDI Talk” and is reprinted here with permission. Contact her at JSeel@ghs.org.

Book Excerpt: Look to others for advice when starting a new CDI program

The Clinical Documentation Improvement Handbook, Second Edition

A savvy CDI steering committee looking to implement a new CDI program should seek the opinion of other facilities in their vicinity, perhaps even visiting other programs and shadowing CDI professionals on their rounds. Such engagement provides anecdotal first-hand experiences to help shape the roles and responsibilities of the CDI staff and it helps the steering committee gauge potential problems.

The group may also decide to enlist the assistance of professional associations; both the American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS) help foster local meetings in various states where members freely discuss program troubles and triumphs. Furthermore, ACDIS surveys its members annually regarding the structure, staffing, and focus of CDI programs.

For example, two studies, an April 2010 CDI Staffing Survey featuring responses from 85 CDI department directors and a July 2010 CDI Program Benchmarking Survey featuring 482 responses from a variety of CDI professionals, both indicated that a majority of CDI programs employ registered nurses as CDI specialists who report to the HIM director.

Whether a facility uses coders, nurses, or some combination of both, and regardless of to whom the CDI staff reports, the goal of capturing complete and accurate documentation should not be compromised in favor of other agendas. Without clearly defined responsibilities, a case manager who also performs some CDI work may push one set of responsibilities aside for another given the limitations of time, experience, and administrative expectation. Conversely, a coder might not pursue a query if tasked with concurrently coding a chart, meeting productivity standards, and maintaining discharged, not final billed (DNFB) goals.

Editor’s Note: This article is an excerpt from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition written by Marion Kruse, MBA, RN and Heather Taillon, RHIA, CCDS.

Q&A: Keeping electronic query copies

Q: Our program does not typically include query information as part of the medical record. If the physician responds to a faxed query,

You've got questions? We've got answers. E-mail mvarnavas@cdiassociation.com

we scan the fax into our electronic record. However, we resolve most queries in person or through a secure messaging system in our EMR (we use EPIC). Once the physician updates the chart, or replies back explaining his/her disagreement to the query, the query is considered “done” and we close the chart. The secure messaging system could be audited, if need be, but is really considered outside the chart.  Should we be concerned about this or change our practices at this point due to additional auditor scrutiny?

A: If you’re using a messaging system for querying, I would just caution you to ensure that the provider is actually adding the necessary clarification to the progress notes or other part of the record.  Also, beware of responses on a fax or other query form if that is the only place the physician clarifies the documentation. The RACs seem to tend to deny those diagnoses since they appear only once or twice and are often omitted from the discharge summary. Many of the RACs are now denying diagnoses that are not included in the discharge summary. Sure, it is not fair, or even representative of the coding rules, but then who’s to stop them?

Editor’s Note: Lynne Spryszak, RN, CPC-A, CDI Education Director for HCPro Inc., Danvers, MA, answered this question. Contact her at lspryszak@Spryszak teaches the CDI Boot Camp and its online version.

Quarterly conference call Thursday

The next ACDIS quarterly conference call will be held Thursday, May 26, 1-2 p.m. EST. ACDIS members have received dial-in

Don't miss this week's quarterly conference call for ACDIS members.

instructions via e-mail. If you have any suggestions for topics for discussion, or a pre-submitted question you’d like the advisory board to address, please e-mail ACDIS Director Brian Murphy at bmurphy@cdiassociation.com.

The quarterly conference calls typically have upwards of 300 CDI-related professionals dial in. ACDIS Director Brian Murphy directs the call, introducing any advisory board members who have dialed in and updating listeners on any ongoing Association business. The board then discusses any submitted questions and listeners can weigh-in on any topic as the discussion progresses by typing *1 on their telephone key pad.

Discussion topics cover a wide variety of concerns from documentation of specific diagnosis such as pneumonia to program structure, staffing, and physician education.

An archive of previous calls is also available to ACDIS members. A digital recording of each quarter’s meeting along with that meeting’s agenda is posted online typically a few days after the date of the live call so those who cannot listen live can still benefit from the shared discussion.

The archives are also worth perusing when you face a particularly difficult topic at your facility or if you are preparing for an education session. In such circumstances, visit the quarterly conference call page, type “Control F” or choose “Find” from the edit menu on your browser. Type the topic you wish to find, syncope, for example, and the browser will highlight any instance of the topic on the page.

Wisconsin’s first face-to-face CDI networking event proves successful

Waukesha, WI

The WI ACDIS Chapter held their first in-person meeting on Saturday, May 21st, in Waukesha. There were 47 chapter members in attendance, a sizeable number given the fact there are 60 members in the group total. Dr. Gamal Eskander, a practicing family physician who currently provides clinical documentation education to physicians, flew in from Nashville,TN, to attend. Dr. Eskander’s presentation covered the clinical topics of congestive heart failure, pulmonary hypertension, acute and chronic cor pulmonale, and differentiation between structural and functional heart disease. Other topics covered as part of the meeting included outlining processes CDI specialists can employ today to prepare themselves for ICD-10 and a session on the physician query process. A raffle was held. The WI ACDIS Chapter looks forward to its next quarterly in-person meeting in addition to its monthly teleconference meetings.