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Tip: The four E’s of staff education

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Brush up on some education tips and tricks!

by Amanda Southworth

Educating CDI staff and physicians alike can be a challenge. With busy schedules, resistant physicians, and a constantly changing healthcare environment, even the most seasoned educator can feel like pulling their hair out.

By keeping in mind four E’s, however, educating becomes a bit more manageable.

Efficient: Educational sessions should seek to get to the point quickly. With busy and fluid schedules, each educational session should have a focused point. Even if the timeframe incorporates a couple different subjects—say, clinical indicators and querying—each section still needs a point and direction. This will cut down on wasted time during your limited education space. [more]

Tip: Diversify your CDI education to keep staff engaged

Every CDI specialist knows how difficult it can be to set aside a whole hour or more for dedicated training and education. With productivity expectations and quotas, cutting out a sizable chunk of time for learning can be challenging. Diversifying CDI education tactics can help engage staff in more meaningful ways.

Though electronic health records (EHR) and technology sometimes complicate the CDI process in select ways, CDI managers and leaders can harness technology to increase educational reach. [more]

Note from the ACDIS Editor: CDI Journal provides training tactics

LA-new headshot

ACDIS Editor Linnea Archibald

By Linnea Archibald

New hire training. Ongoing education. Physician education. Each area holds unique difficulties for the CDI professional in all stages of their careers. Keeping all the CDI staff and physicians on the same page can be a daunting and headache-inducing task. For that reason, the July/August edition of the CDI Journal seeks to outline a few strategies, tips, and tricks from seasoned veterans in the field for keeping your whole team engaged and up-to-date in their CDI education.

Within the pages of the newest edition of the CDI Journal, you’ll find valuable information from a variety of perspectives—from CDI specialists conducting daily reviews, to CDI educators, to the ACDIS Advisory Board members, to the ACDIS leadership team and staff. [more]

Note from Associate Editorial Director: What’s your query metric?

Melissa Varnavas

Associate Editorial Director Melissa Varnavas

Although many CDI program directors wish for national standards for calculating CDI productivity (e.g., a set number of new reviews and re-reviews per CDI specialist per day), “frequent regulatory changes and broad diversity within the industry prohibit a one-size-fits-all approach,” the ACDIS Advisory Board wrote in a White Paper released in December.

While that fact may be indisputable—new CDI staff simply cannot be expected to be as productive as those with multiple years’ experience and programs with expanded record review scopes cannot be expected to turn over as many records as those simply looking for a lone CC/MCC—CDI programs can take advantage of polling research conducted by ACDIS over the years to help establish baseline metrics and program goals.

For example, a 2014 ACDIS website poll indicated that productivity expectations ran the gamut:

  • 32% review 1–10 records per day
  • 25% review 11–15 records per day
  • 18% review 16–20 records per day
  • 13% review 21–25 records per day
  • 6% review 26–30 records per day
  • 6% review more than 30 records per day

The productivity survey conducted in association with December’s White Paper release found 85% of respondents review 6–15 new patient reviews—only 7% reviewed less and only 5% reviewed 16 new records or more per day.

Ultimately, judging from the data, the Advisory Board suggested that “16–24 total reviews per day (new reviews and re-reviews) is an average range for a CDI specialist, with 20 daily reviews being an acceptable goal to account for variability in review focus,” as noted later in the survey.

The latest survey out from ACDIS probes at a number of additional questions related to CDI physician query practices, including:

  • Do you query for clinical validation, i.e., to confirm presence of a documented diagnosis lacking clinical support?  To date, 85% of the more than 200 respondents do.
  • Does your facility have standard query policies and procedures? More than 75% do.
  • Does your facility have an electronic query system either as part of your EHR or another software system? Only 17% don’t.

The survey which will remain open through March 1, also asks important questions about query auditing and monitoring, resources used to craft query policies, and about respondents’ perceptions regarding the effectiveness of electronic systems.

As I often say, ACDIS thrives on membership participation and we need yours to ensure the data revealed in this 2017 physician query assessment represents the true benchmarks of our industry. Won’t you take a few minutes to share your thoughts?

Click here to take the survey. And thanks!

Sunday Reading: Ongoing opportunities for physician education

The CDI Specialist's Handbook

The CDI Specialist’s Handbook

After initial educational efforts, be sure to provide additional CDI training sessions for physicians on an ongoing basis. These sessions should:

  • Inform new medical staff members
  • Provide updated information regarding regulatory and coding initiatives
  • Describe changes to ICD-9-CM (ICD-10-CM/PCS) terminology
  • Provide analysis of how physician responses to CDI initiatives affect outcomes

Some facilities employ highly creative methods for ongoing education in the form of newsletters, posters, and even pop-up boxes when the physician logs into the hospital computer. For example, one hospital system created an electronic screensaver that stated “pneumonia season is coming, don’t forget the importance of clarifying gram positive versus gram negative pneumonia.” Another hospital placed posters with documentation tips specific to surgeons in the bathroom stalls of the surgery changing rooms.

[more]

Guest Post: Convince physicians by showing them the CDI benefit

Don't neglect nursing notes and nursing education when looking to strengthen your CDI program efforts.

Strengthen your CDI program efforts by improving relationships with physicians.

Getting additional specificity is a matter of properly engaging physicians to promote good documentation habits. A CDI specialist often places queries on the physician’s chart and leaves.

Some physicians will never answer. Instead of getting angry that they’re not responding, try calling their office and setting up a time to meet the physician to outline the direct benefit of complete, accurate, and effective documentation beyond diagnostic conclusory statements. Explain to the physician how their documentation matters in the larger context of the business of medicine, both in our current state and within the context of healthcare reform and the transition away from fee-for-service to Value Based Payments, merit based incentive payment systems, and bundled payments.

Better yet, rather than simply telling the physician of the benefits, show him/her the benefits by reviewing a few of the clinician’s charts; maybe those with queries that went unanswered but which could have made a big difference.

It’s really a matter of engaging your physician—that’s what drives them. If you get paid on a merit based incentive payment system—if you treat your patients more efficiently with better outcomes and lower cost—you will get paid for that quality of care. That’s the message we have to get across to physicians—“You have to show your efficiency and care in your writing. You can’t generalize, doc, you need to show us.”

But it’s also a matter of changing our own CDI mindsets. We get too comfortable and don’t want to change. Consultants have a tendency to perpetuate this mindset, promising case-mix index gain and setting standards for chart review and the query process which forces CDI staff to look only at CC/MCCs.

We need to break this cycle. CDI specialists need to think outside the box about how they can more broadly affect documentation beyond CCs and MCCs.

Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, is Executive Director of the Foundation for Physician Documentation Integrity. Contact him at glennkrauss@earthlink.net.

Book Excerpt: Providing Physician Education

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The CDI Specialist’s Handbook

After initial educational efforts, be sure to provide additional CDI training sessions for physicians on an ongoing basis. These sessions should:

  • Inform new medical staff members
  • Provide updated information regarding regulatory and coding initiatives
  • Describe changes to ICD-10-CM terminology
  • Provide analysis of how physician response to CDI initiatives affect outcomes

Some facilities employ highly creative methods for ongoing education in the form of newsletters, posters, and even pop-up boxes when the physician logs into the hospital computer. For example, one hospital system created an electronic screensaver that stated “pneumonia season is coming, don’t forget the importance of clarifying gram positive versus gram negative pneumonia.” Another hospital placed posters with documentation tips specific to surgeons in the bathroom stalls of the surgery changing rooms.

Ideally, a CDI program could hold an annual brainstorming session and assign individuals to work on various aspects of physician education throughout the year. Keeping such sessions a priority encourages the team to generate innovative ideas and ensures physician education remains consistent. Spread ownership of physician training among the CDI team members, so the burden does not always fall on the shoulders of CDI management. This allows CDI specialists an opportunity to gain valuable public speaking and professional development skills, as well.

Target training to specific service lines

To develop further physician support, consider creating service-line specific documentation improvement training. Such education can allow the CDI program to address particular documentation concerns by MDC or body systems. Orthopedic surgeons, for example, should learn the importance of documenting the specific site of a fracture and whether the fracture is pathological in nature. Orthopedics also need to know to document the suspected cause of back pain, the presence of osteomyelitis for a patient with a pressure ulcer with a notation of whether it was chronic in nature, and any secondary diagnoses (i.e., CCs and MCCs).

By paying attention to these specialty services, the CDI program illustrates its understanding of the unique needs and values each physician specialty provides to the facility. Lastly, it shows the CDI department is willing to learn and adapt and work in creative ways to be of assistance to various departments in the facility.

Consider creating a timetable for service-line focus. This may mean tackling an area monthly, bimonthly, or quarterly depending on the variety of services provided by the organization. Work with physician leadership to identify opportunities for documentation improvement, and to identify industry standards for clinical documentation in that area, similar to the process for creating a specific physician query. Be sure to train CDI staff and members of the HIM department and inform all parties involved of the target area and time line.

When the appropriated time comes, try picking a day to review every chart from that service line, leaving routine queries as needed. Other items such as targeted documentation tip sheets, informational posters, and increased CDI presence within that department can increase awareness of documentation improvement efforts. Rotating such efforts ensures no one group gets all the CDI staff’s attention all the time and ensures no department gets left out of the CDI mix.

Remember that ongoing education is not only for the medical staff. Ask particularly responsive, helpful physicians to provide training to the CDI and coding teams on a particular topic. Opening the dialogue to such an extent illustrates a willingness to learn and exhibits programmatic inclusiveness to all involved. Most physicians are teachers at heart and many will enjoy an opportunity to share their knowledge with others. Asking a physician to share his or her expertise on a topic can have positive effects beyond the original intent of group learning.

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

Guest Post: Poll results for physician support

Start new physicians off on the right foot by including a brief overview of your CDI program benefits during their orientation sessions.

Reach out to your physician advisors and any other supportive individuals in your facility.

CDI success depends on physician support and yet, 68% of poll respondents called support either “poor” (10%) or “fair” (58%), during the February 18 ACDIS Radio program “How CDI must adapt to healthcare reform.”

The poll, which garnered an 85% response rate from the program’s 414 participants, asked “How do you describe the level of physician buy-in into your CDI program?” Additional responses included:

  • 2% Outstanding, our physicians fully understand what is in it for them
  • 25% Very good, most of our physicians are invested in CDI
  • 58% Fair, physicians will respond but often out of obligation
  • 10% Poor, many physicians don’t respond to queries or are disengaged
  • 5% Don’t know/not applicable

Only 27% indicated their confidence in the degree and level of physician buy-in of their overall CDI program. This is concerning for two reasons:

  1. At this stage in the game, the majority of CDI programs are mature and have been operational for several years now
  2. Given the longevity of existence of most CDI programs, how can programs continue to operate with “fair” or “poor” buy-in from physicians?

Call to action

Time is of the essence to clearly improve physician engagement. Why? Because good, cost effective patient care, quality outcomes, better care coordination with reduced readmissions, and sustained population health management, all hallmarks of value based performance healthcare models, depends on it.

What can we do to change the situation? We need to change the current CDI model. We need to eliminate perpetual query efforts. We need to understand, and help physicians understand, that complete medical record documentation serves as a communication platform, a tool for the accurate reporting of physician care. This medical record documentation directly benefits all other stakeholders associated with patient care. These stakeholders include other physicians and ancillary care providers, case managers charged with coordinating and advocating for the patient’s care and well-being, physician advisors who fight to insure patient’s receive the proper care in the right setting, post–acute care entities, and, more importantly, the patient themselves.

We need to work hard to dislodge physicians’ misunderstanding that their medical record documentation is merely a necessary evil in the business of medicine, another burdensome task to be rushed through in an overly busy day. Part of our job as CDI specialists is to convince physicians that solid, effective, complete clinical documentation is just simply good medicine and patient care.

Our message must incorporate the ideal that quality documentation is quality medicine and the two are inarguably inseparable.

Enlisting help

Call in the reinforcements. Reach out to your physician advisors, case managers, chief medical officers, vice president of medical affairs, president of the medical staff, and any other supportive individuals in your facility. If they understand the value of CDI, the value of the complete medical record, they’ll be able to explain it to others. They will carry forth the CDI message and address its importance across healthcare department silos. Unfortunately, some physicians equate our efforts as a front to capture more revenue for the hospital, revenue that does not flow into the physician’s own financial bottom line. It’s a fallacy. And it’s our job to dissuade physicians from this notion. Show them how their documentation improves their quality report cards, their readmission rates, and their own financial outcomes.

Lastly, we need to help of ourselves, our own CDI profession. CDI specialists need to stay informed about the changing landscape of healthcare care reform initiatives and demonstration projects. While many CDI programs began as a way to capture additional diagnoses and improve CC/MCC capture rates, healthcare reform is moving payments away from this model to one based on quality-focused delivery of healthcare. We have a certain amount of responsibility to incorporate this information into our quest for the promotion and avocation of complete, accurate, effective, precise clinical documentation.

CDI specialists can remain true to this quest through our present duties and responsibilities in chart review and ongoing communication with the physicians. The form and message of our day-to-day query efforts directly affects whether physicians will ultimately support our CDI programs. The time is now to take a serious hard look at the message we are carrying. The responses to last week’s ACDIS Radio poll serves as a testament to the need for an updated physician message—one that more clearly reflects the true aim of CDI—to improve the quality of the medical record and capture the most accurate description of the care and services provided.

Book Excerpt: Increase physician awareness of documentation importance

Learn about documentation for  SOI from Robert Gold, MD.

Learn about documentation for SOI from Robert Gold, MD.

Physicians in the United States are becoming more aware of the value of clinical data and the relationships between their professional profiles and the International Classification of Diseases (ICD) and Current Procedural Terminology (CPT®) codes they assign, or those assigned for them by others. Certainly, internists are aware of the value of personal professional billing codes, and surgeons are aware of their morbidity and mortality rates. These all relate to the ICD codes assigned for diagnoses, treatments, and procedures performed.

If the clinical documentation and, thus, the codes do not accurately and specifically represent the work a physician does, someone can be inconvenienced—if not actually hurt—with data that poorly reflects on the practitioner’s quality of care.

The healthcare industry has entered a new era of value based -purchasing (VBP), in which a healthcare provider’s statistics will determine whether the provider is preferred or to be avoided. Medicare started the initiative a few years ago, and in 2012, it took its first giant steps. Private insurance companies have jumped aboard and are making their determinations of selection of physicians and hospitals to be used by their clients based on data. The elements of this data include:

  • Cooperation with official practice guidelines for acute myocardial infarction (AMI), heart failure (HF), pneumonia (PNA), postoperative wound infections, and avoidance of deep vein thrombosis (DVT) after surgeries
  • Severity-adjusted mortality rates
  • Severity-adjusted complication rates (patient safety)
  • Frequency of patient safety indicators occurring
  • Frequency of “never” events
  • Frequency of postoperative and postprocedural complications
  • Severity-adjusted length of stay and patient costs
  • Appropriate venue for delivery of healthcare
  • Avoidance of preventable readmissions to hospital
  • Bundled payments
  • Combined payments between hospital and physician for inpatient care
  • Combined payments for outpatient element of patients after hospitalization
  • Combined payments for global care of patients
  • Combined, severity-adjusted payments between surgeons
    and facility

All of these measures are determined through analysis of ICD codes, and an understanding of how the physician’s documentation justifies assignment of the correct ICD codes is paramount for future success of a practice.

Finally, on October 1, 2014, the United States joins the other nations that already use the International Classification of Diseases system, 10th revision (ICD-10), which requires even greater attention to documentation and assignment of ICD codes than ever before. Physician survival in this new value-based world will depend on documentation and assignment of accurate and specific ICD-10  codes. Both will be paramount to success.

Editor’s Note: This excerpt was adapted from ICD-10 Documentation Strategies to Support Severity of Illness Ensure an Accurate Professional Profile, Third Edition, written by Robert S. Gold, MD.

Guest post: The challenges of physician education

Laurie L. Prescott RN, MSN, CCDS

Laurie L. Prescott RN, MSN, CCDS

By Laurie L. Prescott RN, MSN, CCDS

The biggest challenge of being a CDI specialist in my opinion is the education of the physicians. They fly by us like stealth bombers and we have limited face-to-face time to make the impression. Fortunately, the snippets of education we do provide during those brief interactions can be our most valuable tool. So, I try to be ready because I might only get 30 seconds to explain why his or her confirmation of a present-on-admission indicator is so important with a sepsis diagnosis or why we are interested in knowing if the sepsis developed from the dialysis catheter or from pneumonia.

At the end of the day I take an unofficial “inventory” of these conversations and begin to identify other means of getting the information to the physicians.

At my facility, we developed many methods to reach our physicians. We created “doc-u-tips” (little letters we put in their mailboxes on specific subjects) and we include documentation improvement articles in their monthly physician newsletter. We hang posters in their lounge and place them in clear sleeves in the charts to explain documentation guidelines for diagnoses such as respiratory failure and chronic kidney disease.

Drawing from my experience as a nurse educator, I try to follow the mantra “seven times, seven ways,” meaning if you wish to communicate a message you must disseminate the information at least seven times in seven different ways. I once had a physician tell me that you could train a dog with seven repetitive steps but it will take you 21 years to train a physician. I told him that I am too old to wait 21 years for success!

CDI specialists have to face the challenge of how to identify our physicians’ educational needs and we

Don't feel like a stealth bomber when providing physician education. Create a plan that includes a variety of tactics.

Don’t feel like a stealth bomber when providing physician education. Create a plan that includes a variety of tactics.

need to know how to best “package” and “present” our education while ensuring it the information is reliable, based on established clinical criteria. As most experienced CDI professionals well know, physicians are more accepting of the information presented if it comes from their own literature and uses their own established critical guidelines. Sourcing this information to their professional organizations gives me credibility. It shows that I am just not just telling them what we need for coding purposes but asking them to document to the standards established by their own profession.

Lastly, I try to avoid speaking about coding guidelines or what “I need them to say” merely in an effort to accomplish my own job. I encourage them to tell the patient’s story, to provide specific and complete diagnoses, and to provide the diagnostic criteria to support their conclusions.

There are times when I will explain where a specific term will lead in regard to DRG assignment but I try to avoid these comparisons. If I supply them with definitions or diagnostic criteria that explains and supports specific wording of diagnoses they appreciate that. For example, the old challenge of urosepsis versus sepsis. I can explain how ureosepsis will code to a urinary tract infection or I can provide them with the diagnostic criteria of SIRS- showing how their patient meets this diagnosis based on the criteria. This method shows them the meaning of the word(s)/documentation and shows how their choice relates to the patient’s clinical condition.

The ACDIS website and library provides many examples of how our colleagues are meeting these challenges of physician education. I have always felt no need to reinvent the wheel. For example Tiffany Estes, RHIA, CCDS, at UNC- Chapel Hill shared her Physician Documentation Handbook in the Forms & Tools Library. With her permission I am in the process of adapting it for my medical staff. The library is a great way to share information.

Please, let’s expand this conversation: What methods have you found the most effective in reaching your physicians? Where do you find your sources? How do you identify educational need? What “wins” have you been able to celebrate? Do you have a specific challenge you need help with?

I am sure there is someone reading this blog right now that would benefit from your successes or might lend advice to your challenges.

Editor’s Note: Prescott is a CDI specialist at Morehead Memorial Hospital in Eden, N.C. She has more than 25-years’ worth of nursing experience having received her BSN from the University of Vermont and her MSN-ed from the University of Phoenix. She has worked in many aspects of nursing to include med-surg, peri-anesthesia, ICU, nursing administration and nursing education, and began working as a a CDI specialist in 2007.