All Entries Tagged With: "benchmarking"

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.

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.

2012 CDI professionals’ salary survey

The 2012 CDI professionals’ salary survey was sent to ACDIS members on Tuesday, January 24. In less than 24 hours more than 400 people participated. In 2008, 132 individuals completed the survey. In 2009, responses doubled to roughly 300. In December of 2010, nearly 900 people responded.

I restate these numbers for two reasons. First, I want to encourage all those working in clinical documentation improvement to participate. The larger the pool of responses, the more valid the data. If you are a CDI specialist who reviews medical records please participate. If you are a CDI manager or CDI program director, please participate. If you are a physician advisor whose primary responsibility is oversight and assistance for CDI efforts at your facility, please participate.

Second, over the past few years these numbers have illustrated an interesting point, one which we have internalized anecdotally; the CDI profession is growing. While that may seem like an obvious observation, there have been discouraging stories from around the country of late about CDI programs being dismantled, their duties coupled with those of case managers or quality improvement, or worse, abandoned altogether.

In speaking with consultants and many of you, we have pondered the reasons as to why some healthcare systems seem to be ramping-up their documentation improvement efforts, hiring upwards of 20 CDI specialists, while others simply turn their back on CDI.

Some suggest that facilities have too many initiatives underway right now; they have too much to worry about, too many people to hire to accomplish other, higher priority tasks. They worry over compliance with HIPAA’s 5010 technology initiative, implementation of computerized physician order systems and electronic health records, never mind ICD-10 preparation and training and the rest of the worries associated with healthcare reform.

Others suggest that the programs that closed did not do a good enough job analyzing their CDI program’s effectiveness and communicating that success to facility managers. (Read the blog posts “Asset or Liability” by Glenn Krauss or “The Importance of Metrics and Goals on Behavior” by Donald A. Butler, among other great information previously shared here.)

“Once the case-mix index stops improving administrators stop seeing the value in the program,” one CDI specialist indicated during a telephone conversation. We commiserated, talked about all the other ways CDI specialists’ efforts affect facility prosperity and discussed the role of CDI programs will play in the onslaught on changes coming to the healthcare landscape.

I believe that despite these “stories” of short-sightedness the profession of CDI truly is growing. For each tale of sorrow, I have heard of program expansion into areas of outpatient and emergency clinical documentation, expansion and collaboration between CDI professionals and other internal departments such as audit preparation and physician education for the coming ICD-10 needs. Now, all I need is the data to back this up.

Please take a minute to participate in this year’s 2012 CDI professionals’ salary survey.

Oh, by the way, the other great thing about the salary survey is that it gives you a benchmark against which you can compare your salary to those performing similar tasks. Does anyone out there think it might be time for a raise?

Here is a sneak peak of what people indicated they earn thus far.

Searching for the best of the ACDIS blog

What are your favorite posts?

In response to Don Butler’s call for the most popular ACDIS Blog posts, (What would your favorite blog post be?)I decided to take a look at our “analytics” to find out statistically which posts drew the most attention.

I looked at the growth of the ACDIS Blog since November 21, 2009 year-over-year through November 21, 2011. According to the dashboard, there were a little more than 45,000 visits to the site from 2010 to 2011 up from 33,500 visits from 2009 to 2010. There were 87,000 page views this past year up from 68,000, with roughly 20,500 absolute unique visitors up from 14,500 in the 2009 to 2010 time period.

In terms of content it seems like the post “Does your hospital use the Epic software system, let’s hear about it” has garnered the greatest number of visits with more than 3,700 page views, followed by “CMS releases crosswalk for ICD-9 to ICD-10 Translation” with 3,300 page views.

The rest of the top 10 included:

3. Malnutrition continues to be area of clinical concern

4. Query questions: When should you not query

5. Q&A: Querying for SIRS when clinical indicators are present

6. Final changes proposed to ICD-9 code set

7. Clinical Documentation Improvement: What is your definition?

8. Physician query handbook released

9. Feeing the brain on malnutrition documentation

10. Pressure ulcer coding and staging

While this list may have some data behind it, I’m not 100% sure I believe what the data illustrates. I have a difficult time believing that CDI specialists perusing the ACDIS Blog really loved reading the brief announcement regarding CMS’ release of General Equivalence Mappings (GEMs), a crosswalk of sorts between the ICD-9 and ICD-10 code sets. Similarly, while I understand that Epic is a large integrated healthcare information technology software provider, and that this particular post has probably generated the most “comments” for any post on the ACDIS Blog, maybe that only illustrates that Epic customers need more networking opportunities.

Other items which hit the top 10 are a bit more interesting as they seem to be common topics of discussion and areas which CDI specialists constantly seek updated information such as physician query best practices and commonly queried conditions like malnutrition, sepsis, and pressure ulcers.

To reiterate Don Butler’s initial question then, what would you, as the ever-growing number of ACDIS Blog readers, like to see more of in 2012? And… if you are interested in contributing, don’t be shy. Shoot me an e-mail mvarnavas@cdiassociation.com.

Asset or Liability: How do you describe your CDI program?

A recent discussion on the ACDIS CDI Talk list serve provoked me to ponder: Is your program truly an asset

Don't use measuring tape to determine your CDI program success.

to your organization? Does it promote complete and accurate clinical documentation reflective of patient severity of illness (SOI), medical complexity and quality outcomes that justify the costs of care? Or is your program really a liability to the organization?

The CDI Talk discussion asked how programs calculate their return on investment (ROI). One response pointed out that any monthly report of CDI case mix change and financial reimbursement effectiveness must include a disclaimer informing readers about the fact that such data is subject to adjustment for transfer DRGs provisions inherent in the inpatient prospective payment system (IPPS). So, here’s my two-cents on the issues raised.

Another adjustment to consider

An effective CDI program can be a significant asset or a significant liability depending upon how the program is initially structured, set up, rolled out, and carried forward with daily CDI activity. Unfortunately, a majority of CDI programs center their metrics (proof of their ROI) on increased financial reimbursement to the hospital. This takes away from the overall potential of the CDI program for the hospital as well as the physicians. That’s because this narrow focus on reimbursement positions CDI programs as revenue enhancement programs. It forces CDI specialists to focus on the capture of CCs/MCCs and “more specific” principal diagnosis. And this, in turn increases risk and liability for the hospital.

Consider the following common analysis conducted by CDI programs to prove their effectiveness:

• Number of queries left by the CDI
• Number of queries that change the principal diagnosis
• Number of queries that add a CC/MCC
• Number of physician queries responded positively to by the physician
• Number of physician queries not responded to by the physician
• Number of queries left in the record which the physician did not agree to clarify/add documentation
• Potential capture rate of monthly CC/MCC not obtained due to physician disagreement
• Change in monthly case-mix-index
• Time from admission until record was reviewed and DRG worksheet completed
• Average number of times a record was reviewed per admission

While reviewing these statistics can provide insight into a CDI program’s success, commitment to these types of matrices as the sole indicators of a program’s success can stymie a program.

A primary goal of CDI professionals is to improve overall clinical documentation in the record for purposes of accurate, concise, and effective reporting of patient acuity/SOI, physician clinical judgment, medical decision making, and resource consumption through specificity in documented diagnoses.

One of many “by-products” of this stated goal of CDI is that the resulting reimbursement more closely approximates the care provided. However, strict focus on financial reimbursement benchmarks creates incentives for staff to omit queries that don’t affect payment or increase queries for conditions that do. This, ultimately, artificially creates a rosy ROI picture for the CDI program. It also increases financial risks as auditors data mine, down-code, deny, and ultimately take back reimbursement from erroneously documented and coded cases.

Now you see it, now you don’t

In my experience, many a RAC denial is fundamentally related to CDI program deficiencies. Often a query results in the physician documenting a diagnosis in the record just once. The query may have asked the physician to clarify the principal diagnosis, secondary diagnosis, or sought to add a CC/MCC to the record.

These queries frequently include:

• Aspiration vs. community acquired pneumonia
• Sepsis with change in mental status vs. sepsis with acute encephalopathy
• COPD exacerbation with hypoxemia vs. COPD exacerbation with acute-on-chronic respiratory failure

The physician may respond to the query by including the specified diagnosis or diagnoses in his/her next progress note yet not include these same diagnosis specificity in the continued care progress notes and discharge summary. According to our previously discuss benchmarks, the CDI manager counts the physician’s response as a “win,” and moves on to the next chart review.

The physician’s conclusory diagnostic statement without accompanied discussion of pertinent clinical facts and information constitutes insufficient documentation from an “outsider’s review” perspective. The RAC or other third-party payer retrospective reviews frequently down-code or deny these claims due to such documentation deficiency.

Effective CDI programs should incorporate more than financial measures in their program benchmarking.  Clinical documentation beyond mere diagnostic conclusory statements supporting clinical presentation of the patient as well as the clinical facts of the case is essential for revenue integrity and continuity of care. Consider the following found in the most recent Statement of Work for the RAC:

“Clinical validation is a separate process, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented. Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder.”

Now is an ideal time to consider your answer to the “asset vs. liability” dilemma, take inventory of the processes of your CDI program, and aim for positive process changes in the new year to ensure your program’s contribution to the healthcare organization.

One may wish to determine how many RAC denials were associated with disallowance of principal or secondary diagnoses (CC/MCC) on the basis of insufficient documentation. The continued success of the profession of CDI is predicated upon adapting to changes in the healthcare marketplace. Renewed emphasis on a “visionary” mindset versus complacency will ultimately govern the true success of your CDI program.

CDI Productivity Benchmarks (A CDI Talk topic)

ACDIS surveys, reports, and polls, can help answer productivity questions.

There was an excellent conversation string started on CDI Talk a couple of days ago about productivity measures and staffing models. I provided one of my typical responses there and realized that it might be worth developing into a quick, short(er) post.

The original question asked about daily expectations for an individual CDI specialists as far as initiating new cases and following up on existing cases, as well as expectations for reviews per number of discharges per year.

A lot of excellent replies, comments and sharing followed.  I do shy away from quoting any specific response (you know just like Vegas, what happens on CDI Talk stays on CDI Talk), but one of the repeated observations was how difficult it is to come up with a single figure of merit due to a number of program variations such as:

• number of individuals
• program focus
• paper vs electronic record (and which electronic record system a facility uses)
• physician collaboration
• CDI staff experience level and learning curve
• additional roles/focus (ROM/SOI, POA, RAC, core measures, etc.)
• complexity of patients

There are few (if any) true benchmarking resources that I have found outside of ACDIS.  Consultants certainly have their own models but that is not the same as an objective “what is being achieved”.  All three of the following are worth reading carefully.

• 2010 Physician Query Benchmarking Report
• 2010 CDI Program Benchmarking Survey
• April 2010 White Paper on CDI Staffing Survey : The respondents to this survey were mostly managers or leaders and only one response per hospital was permitted.  This report also nicely summarized discussions by the CDI Work Group about factors that affect CDI productivity.
• For an annual volume of discharges, the on-line poll (#36, Dec 2008) suggests a median of around 1,700 discharges/year/CDS.  It shows an interesting distribution, with a big peak at >2,500, and then the next high point the two elements between 1,300 and 1,900.  There are other on-line ACDIS polls that also provide some insight.

Let me briefly summarize some of the ACDIS survey data.  I will use the 2010 Physician Query Benchmarking Report, though the other sources generally agree.

Items that influence productivity:

• Frequency of concurrent review: 58% daily, 24% every other day.
• Majority of queries: 63% written paper based, 20% written electronic, 3% verbal, 12% equal mix written and verbal
• Do you query when there is not a financial impact: 43% always, 44% frequently
• Do you use templates for written queries: 31% always, 36% frequently, 16% sometimes, 13% never.

Direct productivity benchmark measures:

• Do your CD I specialist’s have a set query quota to meet: 56% no, 38% yes (the median point for that query quota appears almost 25% queries).
• Median query rate about 18%
• Median physician response 87% (with a clear break for >70% suggesting an absolute minimum)
• Median Physician agreement 88% (again, >70%)
• Median new charts per day of 12 (majority between 6 & 25)
• Median repeat reviews per day of 12 (most 6 to 20)

Most sources suggest an average combined total of charts reviewed around 25 charts.  Unfortunately, when extrapolating the daily numbers, they don’t match up with what is commonly discussed for an annual productivity model broadly between 1,300 and 1,900 (i.e., 20 to 25 working days a month times 12 new reviews daily times 12 months gets you to >2,400 cases a year).

The Problem List Project: Managing Post Acute Care Transfer DRGs

Michele D. Johnson, RN, BSN

by Michele D. Johnson RN, BSN

The length of stay (LOS) for coronary artery bypass graft patients and valve replacement patients at York Hospital (YH)/ Wellspan Health was significantly higher than the Medicare geometric mean length of stay (GMLOS) according to results of a record review from October 2007 through December 2008. So the hospital administration formed a work team to identify why YH LOS differed so much from the transfer Medicare DRG GMLOS.

In early 2009,  the work team observed that post acute care transfer (PACT) DRGs resulted in a decrease of $4 million in our expected Medicare reimbursement in fiscal year (FY) 2008. After investigation, the work group determined that YH had an unexplained higher-than-expected distribution of cases in the cardiovascular service line with complications or comorbidity (CC) rates that affected DRG assignment.

The group reviewed a sample of 102 cases and determined that 32 of those cases had evidence of acute respiratory failure that were appropriately documented and coded. The YH physicians documented acute respiratory failure as the reason for a post operative pulmonary consult which increased in LOS as determined by the DRG formula; however, the assigned DRG and its associated GMLOS differed from YH clinical care standards.

After researching and reviewing the medical records, the documentation team found acute respiratory failure did not always, or even most of the time, actually increase patients’ LOS or use of resources.  The majority of the patients did not experience unexpected significant respiratory issues that required extended post cardiovascular surgery LOS.  In fact, many of our patients had shorter LOS than indicated by the Medicare GMLOS.

The documentation improvement team met with the pulmonary medical director to establish a better definition of acute respiratory failure that acknowledged DRG requirements. The CDI team helped the director understand how Medicare guidelines determine what diagnoses lead to increased LOS and emphasized the importance of documenting well-supported diagnoses.

The CDI team realized that the hospital staff lacked a common understanding of which co-morbidities affect the patients’ expected LOS.  To help facilitate awareness, the team developed a tool (available on the ACDIS Forms & Tools Library) to help identify and track pertinent medial issues with the patient’s working LOS. The team also developed a problem list tool to help identify DRG diagnoses with LOS timetables. A pilot program for the new problem list was implemented and incorporated into clinical rounds and medical record documentation.

The team tried to identify a probable discharge date for each patient ± 1 day.  The expected DRG and LOS also were incorporated into care management activities and staff communication during patient rounds.  We use the problem list to help us better manage the LOS and better understand the transfer DRGs.

Currently YH is working to incorporate the problem list into patients’ electronic health records. When the PACT DRG list was expanded in 2007, Medicare stated that the financial impact of the transfer DRG formula was neutral on hospital DRG reimbursement if DRG assignment is accurate. Our study suggests that this premise is valid and hospitals should assess documentation practices to ensure accurate final billing and coding.

Editor’s Note: Johnson is the documentation specialist supervisor at Wellspan Health in York, PA. Contact her at mjohnson3@wellspan.org.

CDI industry outlook survey: Your participation needed

Your input counts! Participate in the CDI Week outlook survey.

Dear ACDIS Blog Readers,

The Association of Clinical Documentation Improvement Specialists (ACDIS) is sponsoring the industry’s first Clinical Documentation Improvement Week on Sept. 18-24, 2011. As part of the week’s offerings, we are providing an industry outlook survey on a handful of hot topics in the CDI industry. The results of the survey will be made publicly available.

Please take a few minutes to complete the survey by clicking here.

If you cannot access the survey, please copy and paste the following link into your web browser:

http://www.zoomerang.com/Survey/WEB22CLLVQG99K/

Thanks for your participation, and if you have any questions about the survey or Clinical Documentation Improvement Week don’t hesistate to e-mail or call.

Take care,

Brian

781-639-1872, ext. 3216
bmurphy@cdiassociation.com

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: 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.