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Book Excerpt: Establishing appropriate rapport

Clinical Documentation Improvement Specialist's Handbook

The Clinical Documentation Improvement Specialist’s Handbook, second edition

One of the most convincing reasons for establishing a concurrent documentation review program is the ability to discuss a patient’s record while the details of the patient’s case are still fresh in the physicians’ mind. Such interactions are as important for resolution of the medical record documentation as it is for providing ongoing education for the physician. Not surprisingly then, many experts encourage facilities to maximize opportunities for verbal interactions between the CDI team and the physician staff, whether it is on the patient care unit or through meetings in the physician lounge. To do so, however, CDI specialists need to exhibit a unique set of interpersonal skills. the CDI specialist must be both positive and professional in his or her interactions with physicians but they must also be able to interpret the physician’s body language at the time of the discussion and be able to weigh and recall a particular physician’s communication preferences over time. Such skills may be summarized by the colloquialism “know your audience.”

For example, Dr. Smith may respond well to e-mail communication but become visibly uncomfortable, aggressive, or reclusive when approached on the floor of a nursing unit. Conversely, Dr. Adams consistently ignores written queries left in the medical record and does not return phone calls. Approach him during his routine rounds, however, and he will answer multiple CDI questions happily.

Beyond understanding the physician’s preference for type of communication, the CDI specialist must also be aware of the personality type of the physician. A process-orientated physician, for example, may respond positively to a CDI specialist who explains how his or her documentation in the medical record translates through the HIM department, billing, and, ultimately, reimbursement and quality data reporting. A results-orientated physician, however, would see such discussions as a waste of time, preferring to understand how the process will affect him or her directly, instead. The ability of the CDI staff member to not only be aware of these different dynamics, but also to adjust their queries and education accordingly can appease wary physicians and earn physician support for the CDI program overall.

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.

Q&A: Communicating expectations to achieve excellence

Do you know what is expected of you? Do you have clearly communicated goals for how to grow professionally?

Editor’s Note: I recently came across this question and answer in one of our sister publications Nurse Leaders Weekly. In this instance the use of the word “quality” does not refer to a hospital’s quality assurance or quality indicator program but to the overall quality of a given effort. The question regarding how effective communication enables a program or department to advance its effectiveness and implement and achieve new goals for its staff applies not only to “nurse leaders” but leadership in every aspect of healthcare—CDI included.

I am sure that you have all had a particularly influential manager or someone you thought was a really great boss at one time or another. If you had that person in front of you now, what questions would you ask him or her? How did their communication skills help your awareness of your responsibilities?

Q: How does communication factor into the success of my quality improvement plan?

A: Good managers know that quality does not happen by fiat or executive order but is the result of staff members’ comprehensive understanding of what is expected of them, why it is appropriate to expect it, how they will be supported to deliver that performance, and how they will be evaluated according to defined criteria.

Communication is core to:

  • Defining the expectations of the organization for each employee’s performance
  • Clearly linking those expectations to the mission of the program and the larger organization
  • Outlining for employees how their individual and team performances are measured and evaluated, and keeping them informed of the results
  • Listening to employees’ thoughts and ideas about potential improvement, born of direct experience in delivering care and service
  • Sharing with employees the progress and knowledge developed elsewhere in the organization, and outside it, which may help employees improve individual and team performance

Reminder: Eight tips for social media etiquette

Does the social medial world sometimes make your head spin? Here are some simple tips to help you.

Do you mix your personal and professional lives on your Facebook page? I separate my personal and professional relationships on Facebook. My personal life is just that, and I don’t need or wish to share some things with my professional associates. There’s nothing randy, more like exchanges with my 20-something nephews, girly gossip about fashion and martinis, or grumblings about local politics. I don’t play Farmville (and have no patience for such postings), don’t care about daily horoscopes, or 99% of posted YouTube videos.

These posts don’t belong on professional pages. Facebook gives us a fabulous opportunity to network on the topics that bind us as colleagues. We can share ideas, techniques, and processes. We can ask one another for advice and guidance.  We can commiserate with our cyber friends about our jobs and careers, encourage those who undertaking new challenges, and cheer for those who achieve their goals.

Most Facebook pages are open to the public, which means your comments, posts, and pictures are searchable. You need to be very careful about what you say and post on Facebook—or on any social media platform, whether on a personal or professional page.

I found a Facebook etiquette list published by the Association of Women’s Health, Obstetric, and Neonatal Nurses and got their permission to adapt it here as recommendations for our association’s interactivity on our social networking sites including Facebook, LinkedIn, CDI Talk, and soon (believe it or not) Twitter.

Consider these tips for smart social media conduct:

  1. Be respectful of people’s comments. If you don’t agree with a comment, state your point without being rude, confrontational, disrespectful, angry, or vulgar. Better still, don’t reply at all.
  2. When you post a comment, ask a question, or respond to others, give your opinion about important topics in a professional manner.
  3.  Remember HIPAA – don’t post patient information in ANY form. Don’t post particulars about a patient or a situation that might be identified. Don’t post photos of patients.
  4. Share articles from reputable sources that you believe will educate your peers on different topics. Take a page from Glenn Krauss and Lynne Spryszak who frequently share links to government auditors’ transmittals on the ACDIS Facebook page.
  5. Be careful how you express an opinion about your current facility, work, or a co-worker. Remember that your managers and co-workers are also interested in these CDI professional networking opportunities and may be members themselves. Don’t forget that your employer and/or future employer could view what you have posted. Don’t divulge confidential and/or proprietary information and don’t spread gossip. If you would not want them misconstruing your conversation if they overheard it in the hallway, don’t put it on the Internet either.
  6. If you choose to post pictures, select those that are in good taste. If a photo of a friend is unflattering (and you’d be horrified to see that image of yourself posted for all to see) don’t post it.
  7.  Don’t spam. Some people like to eat it (believe it or not) with fried eggs, but reposting advertising or promotional materials to social networking sites isn’t good etiquette.
  8. Ask questions of your peers and participate in Wall or Discussion Boards regarding a specific topic. Share your expertise when you can, and thank those from whom you take suggestions.

Note: This list was adapted and reprinted with permission from the Association of Women’s Health, Obstetric, and Neonatal Nurses, www.awhonn.org. For

Social Media: Untangling the webs

Don't let participation in the World Wide Web get you tangled; simply practice professional discourse.

There are risks to activity on social media. For example, consider the case of a student doing a senior seminar experience (these can be an avenue to one’s first professional job) at a facility.  Unfortunately for this individual, before the facility moved to hire her, her potential employer went and looked at her Facebook page. The result: She was immediately no longer considered for any open position. I’ll leave the details out.

What about Google?  Have you ever Googled yourself, a potential date, an applicant, or a professional service you’re evaluating? Even out of pure curiosity?

Reviewing an individual’s social media presence and activity is a legitimate tool for potential employers and current managers.

I believe there ought to be some degree of latitude with regard to purely personal social activity, of course. Sites like Facebook were built with an aspect of entertainment and socialization imbedded. But the bottom line is that any activity on the internet is captured; potentially stored forever.

The same is true for the ACDIS Blog, CDI Talk, and related ACDIS social media venues.  Even though CDI Talk is for members, the network of membership is at least a couple thousand, and everyone has friends… or colleagues…

Though several recent unfortunate examples come to mind, I’ll only share my own personal experience.

Not too long ago I replied to a CDI Talk discussion but as soon as I hit send, I saw the context of what I’d written in a different, less appealing, light. I called the author of the original post and apologized. I was relieved to learn that this individual had not taken my response in the negative vein as I’d feared but in the positive light in which it was intended.

The networking avenues afforded to us individually through our ACDIS membership are intended to allow us to air our concerns and express our frustrations, to allow us to network with each other and to learn from each other.

However, this network is open to all members of ACDIS—the peers who share your opinions and those who may not; the friends you may have made at a nearby facility and colleagues who work alongside you at your current hospital.

You may find your words and thoughts in the hands of your current boss, or being considered 10 years from now when you are seeking new opportunities.

Don’t get the wrong idea; there is a genuine upside to participating in the social media networks that are now open to our profession. I love participating and conversing with my colleagues. My activity on the blog and on CDI Talk has already afforded me with great opportunities to meet people, learn much, and bring it all back “home” to improve our own CDI program. Despite the potential pitfalls of participation I do not plan to stop what I am doing. In fact, I wish there were more participants.

However, I often do wait before I hit send. I reread my statements and ponder how the message might be perceived. I question if I am revealing too much. I wonder if those reading my response could be offended in anyway. That isn’t to say I stifle my opinion. I just want to be sure to keep my professional integrity intact. Please do join us in the electronic networking that’s offered.

Just be careful out there.

Celebrating CDI success stories

Don't let daily pressures get you down. Take time to review your CDI program successes.

Thinking about CDI programs that haven’t worked out, programs  one might call “failed,” and facing a bit of deadline pressure on some projects here at work, got me feeling a bit blue recently. So, frankly, I feel like taking a moment to reflect on a few of the successes that CDI programs can (and should) brag about.

Staffing growth: Often a CDI program starts with one or two individuals but is able to add staff as time goes on. Such growth often illustrates a need for additional staff who can continue to conduct thorough reviews when the existing staff are overloaded and provide for vacation coverage, etc. The recognition of the value of continuous CDI staffing points to an administration that understands the value of CDI and perceives the need to expand the program. Expanding the CDI program to a larger patient population, payer pool, and focus illustrates the benefit of increased attention on total medical record completeness and accuracy (pushing past the largely financial focus), whether that be due to purely internal conversations, broader CDI professional discussions (such as those explored here on the ACDIS Blog, or via other avenues such as CDI Talk, and other ACDIS publications) or to some extent influenced by external issues such as quality/core measures or RAC.

Pride of achievement: Outside of one’s own facility, CDI professionals can take pride in helping to mentor other CDI programs and their staffs. Participating in a state or regional meeting is one way to talk about your own program’s successes and learn from the successes (and failures) of others. Furthermore, hosting a CDI networking meeting that others hail as an outstanding success can be a real morale booster for yourself and your whole team! (Just look at the various posts on the ACDIS Blog about the many wonderful programs offered at state meetings.)

Through participation in local/regional networking events you will soon be able to brag about:

  • Preparing a significant presentation that was well received.
  • Incorporating program improvement initiatives associated with casual conversations held during meetings.
  • Watching documentation trends develop and improve due to query discussions and documentation improvement opportunities discussed at the meetings.
  • Mentoring a new CDI specialist and watching their awareness “click.” (Of course, that experience can be repeated again and again, although sometimes it takes a long time to get to complete awareness).

Growth of our professional organization: There were more than 600 people at the national ACDIS conference in Orlando this past April. Given the state of the economy and the national feeling regarding healthcare expenses, a 20% growth in registration for our professional association is simply amazing. There are more than 2,700 ACDIS members and more than 12,000 subscribers to bi-monthly e-newsletter CDI Strategies. If that’s not growth, I don’t know what is.

Expansion of CDI positions: The number of new programs (at least anecdotal) continues to grow. Look at the number of open CDI-related professional positions available. You can look at the ACDIS Job Positing page or just conduct a simple Google search to see the influx of openings. There’s no doubt that our experience and expertise is in demand. (Have you received any calls from recruiters lately?)

CDI program development: National trends revealed through ACDIS surveys, online polls, and CDI Talk conversations show an increased focus on complete and accurate documentation captured in the medical record and a shift away from the traditional origins of a CDI program focused on queries for financial gain. Additionally, the maturation of the professional can be seen in the increasing number of CDI specialists who have obtained their CCDS credential and who have volunteered to take on additional projects for ACDIS and AHIMA to further the profession.

In short, the sophistication, poise, and professionalism of our membership amazes me, inspires me, and drives me. Here are two examples of my personal inspirations:

  • Bravo to the program at Wake Forest University Baptist Medical Center (WFUBMC) in Winston-Salem, NC (featured on the NCACDIS site) who recently added four new CDI specialists to the existing strong team of 11. This is a program that has been in existence since 1999 and several years ago achieved a complete shift of focus to encompass severity of illness and documentation accuracy. With the additional staff, I understand they are going to be reviewing ALL inpatient medical records.  In addition, their performance in regards to metrics such as mortality index is something to really strive for!
  • There are several “voices” on CDI Talk that I eagerly look forward to reading. I learn something new all the time and frequently forced to contemplate subjects a little deeper. I feel I grow professionally a bit every day because of the generosity of these folks who contribute to our CDI community.  I am look forward to the opportunity to participate in conversations with peers that lead to personal reflection and professional growth.

I’d love to hear about your successes and moments of pride and joy be they large or small, personal or national. When was the last time you CELEBRATED at your organization? Make note of it here or  write me back. If you haven’t celebrated in a while consider setting aside the week of September 18-24, the newly designated Clinical Documentation Improvement Week to spotlight your program’s achievements.

Commit to your own personal and professional achievement

There have been numerous posts on the ACDIS CDI Talk list serve regarding frustration with daily duties and responsibilities of a CDI

Everyone wants a gold star for their accomplishments. The question is what are you willing to do professionally to earn it?

specialist. Many, it seems, see their role primarily as cashier and banker for hospitals. Unfortunately, the underlying premise of most (but not all) CDI programs is increased reimbursement for the hospital. As a hospital’s CDI program evolves and matures, it frequently migrates away from strict reimbursement focuses and begins to incorporate other vital elements of CDI including reporting quality and other data elements that directly depend on clinically relevant information—information that eventually gets translated into ICD-9 code assignment.

Naturally, any job can become mundane from time to time as the individual develops strong core competencies and masters the position. I certainly can understand that type of “boredom.” I was the manager of a Burger King restaurant, once. It was my first job out of college. I earned $24,000/year. I thought I was going to be rich. Then I did the math. I added up how many hours I worked and lamented saying, “Welcome to Burger King, may I take your order” at 1 a.m.

I remember a similar frustration with the day-to-day grind of my next job—a bill collector. “Hello is this Mr. So and So? I am calling because I see a balance on your account, can you send me a check today to clear up the balance?” Sometimes the debtor would tell me he/she had just sent the check. I knew they hadn’t. I can’t tell you how many times I wanted to tell them so. Soon, I knew, I’d see his or her name back on my call list. Talk about a mundane day-in and day-out type of job. It just wasn’t for me. Soon I’d had enough. I expanded my horizons, explored other career options, decided on a profession in health information management, and here I am today.

Expanding your horizons

I attended boarding school since third grade. The average class size was five or six students. At the end of each quarter, the students’ grades were posted on the blackboard for all students to compare. The motto was: “If you are not getting straight As, you have more homework to do.” If there is anything I learned during that time, it was that in order to be successful you must challenge yourself to be the best in any project or endeavor you are involved in.

Although no longer competing for the best grade in class, I still adhere to the same principle. Instead of challenging myself to achieve good grades, I am challenging myself to continually learn and identify how I may become more valuable to the organization I am involved with, be that as a consultant or as an active CDI specialist on the hospital floor. I always ask myself:

  • “How can I make this job more interesting?”
  • “What additional areas can I incorporate into my present duties?”
  • What new responsibilities can I tackle that will make the position more valuable to me personally, as well as to the organization and co-workers I interact with?”
  • “What other areas can I see myself potentially growing into as I advance my career?”

This philosophy has served me well and I am convinced this same philosophy can be applied to the larger CDI profession, as well.

The evolving CDI role

So what can the individual CDI specialist do to advance the role of his or her CDI program? What can you do to challenge yourself beyond the traditional role of clarifying clinical documentation through written and verbal queries?

Plenty!

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Countdown of top leadership qualities

You know those somewhat helpful hints you most often find in Women’s Day magazine but which have cropped up recently on web browsers’ homepages? They’re usually things like “8 great meals to make for dinner tonight!” or “10 helpful hints to make your bathroom better.” Inevitably I find myself sucked into these tasty lifestyle tidbits.

Sometimes they’re ridiculous, like the one I read recently about how to operate e-mail effectively, and sometimes they surprise me by offering a little ray of insight, like this one, from US News & World Report, offered “7 Things Your Boss Should Never Say to You.” While I disagree with the negative premise of the piece (why not address the article in the affirmative and speak about what to do rather than what not to do), I found the following excerpt motivational:

“Leaders lead by inspiring, teaching, encouraging, and, yes, serving their employees. Good leaders never need to threaten. So keep your word, set a good example, praise in public, criticize in private, respect your employees’ capabilities, give credit where credit is due, learn to delegate, and when you ask for feedback don’t forget to respond to it.”

Sounds like a lot to live up to. But it reminded me of Stephen M. R. Covey’s “13 Behaviors of High Trust Leaders,” a bookmark of which I posted on the bulletin board above my desk. They are:

  1. Talk straight
  2. Demonstrate respect
  3. Create transparency
  4. Right wrongs
  5. Show loyalty
  6. Deliver results
  7. Get better
  8. Confront reality
  9. Clarify expectations
  10. Practice accountability
  11. Listen first
  12. Keep commitments
  13. Extend trust

No matter what your leadership “position” may be at your facility, you no doubt play a leadership “role” in your CDI


You don't have to be a manager to show good CDI leadership.


program. Would you ever walk up to Dr. Adam Adams and criticize him for not writing renal failure in the discharge notes while he was in the middle of a conversation with several other physicians? Of course not! You’ve got that “praise in public” aspect of effective leadership down! You’re a born leader!

Through your interactions with coders, physicians, managers, even other CDI team members you have an opportunity to effect change and improve physician documentation. To do this consistently you must, even at a subconscious level, employ these effective leadership tactics. Why not spend a few minutes every once in a while considering them on the conscious level? Take a moment to think back over you action today and give yourself a little two minute self-evaluation. Did you set clear expectations for yourself and others? If you demanded that Dr. Sally Sallison be sure to get that documentation into the record before days end, maybe not… But if, instead, you listened to the needs of others, clarified your expectations in order to deliver positive results, leadership may well be your forte.

If you have good example of CDI leadership at your facility leave a comment here on the ACDIS Blog. We’ll give a prize to the best example of effective leadership.

Thankful for CDI community collaboration

Over this past year, I’ve had the tremendous honor and pleasure to engage in substantive conversations with at

Everyone has something to say, what can you learn by joining the conversation?

least three organizations. This has actually been a humbling experience for me — that ‘someone’ out there felt strongly enough of my knowledge, ability, experience, and/or writings that they sought my ideas on CDI. I know I learned a lot through the process of reflection and discussion that occurred. I feel I gained so much more than I offered.

This ‘jazzed’ feeling I experienced during those conversations is the same that I’ve felt every time I’ve been able to attend a gathering of CDI professionals, every time I’ve had the opportunity to speak and teach about CDI or documentation, every time I’ve had a reflective exchange on CDI Talk, or every time I’ve enjoyed any sort of stimulating conversation.

Seems to me, these opportunities I’ve enjoyed are part of the broad concept of networking and collegial professional relationships. This is one of the strongest characteristics I feel we possess as a nascent profession — collaboration, mutual support, and exchange.

This is an important avenue for us as we advance our professionalism.

I am deeply grateful that I’ve had a variety of such experiences. I hope that many others have had the honor to feel this excited about (and due to) our CDI profession.  Equally, I wish for everyone a coming year filled with professional satisfaction and fulfillment.

ACDIS introductions: Melissa Varnavas

In yesterday’s blog I explained how I’ll be introducing ACDIS professionals to give you a little insight into the people behind the organization. Since these “intros” were my idea, everyone said that I should be the first person in the proverbial hot seat.

Because I consider myself a writer (I spent about a decade writing and editing my hometown newspaper and recently earned my master’s degree in creative writing), part of my passion for CDI comes from the fact that I get to put together most of the ACDIS publications including:

Another fun part of my job is helping local groups of CDI specialists gather for networking events. You’ll see me write this again and again during these introductions as other ACDIS staff express similar opinions, but the real joy of arriving at work everyday comes from all of you. CDI professionals are an extremely dedicated and giving group of individuals who are hungry for information and willing to share their experiences in order to help others.

When working with local chapters I help start-up groups find other CDI professionals in their communities and provide some initial outlines for how to get going. I work with local group leaders to post meeting information and generate agenda ideas if needed. I’m happy to say we have groups all over the country from Maine to California. If there isn’t one in your neck of the woods yet and you’re interested in helping get one started, just give me a call and we’ll see what we can do.

Let’s see… what else can I tell you about my work with ACDIS…

I’m a book editor here, as well. That means when you tell me that you’d really like a book to help you with a particular subject I get to work researching the topic, finding the experts in the field who’d make good authors, and helping to make sure all the information you need is included in the book.

Mr. Murphy and I will be splitting the task of producing and moderating audio conferences in 2010, so if you have an idea you’d like to hear some speakers dissect just let me know and we’ll see if we can fit it into the schedule.

Phew, I feel like I’ve babbled on and on… Well, I’ve asked everyone else to answer some common personal questions so I’d better answer them too. Here goes:

That's my husband Chris and I enjoying a spring day at the beach.

I’m 36 years old, married, no children (I do have 10 nieces and nephews ranging in age from 23 to 2 who keep us pretty busy). My husband’s name is Chris Terrell. He teaches special education in Beverly, MA, plays guitar and sings in the band Playing for Crickets. (We met 12 years ago when he was in a band called Guava Jelly, I think Playing for Crickets is a better band name, don’t you?)

My favorite food is French fries, particularly from this restaurant that’s a short walk from my house. It serves them dusted with rosemary sea salt and a tartar sauce (I know weirder than fries with mayo but it is amazing). Couple them with one of Soma’s signature martini’s (my mother loves the banana bread one) and it’s a great night for me.

I’ve already said how much I enjoy writing so in terms of hobbies I guess I have to say writing. But after a day full of word smithing I like to unwind with a walk by the ocean. Which is convenient since I live about a block away from the beach.

I think that’s it for me. If you like listening to Nora Jones or Tito Puente, have a father who was a printer prior to retirement, a passion for Rilke, or want to chat about goings-on in the CDI world give me a call at 781/639-1872 ext. 3711 or shoot me an e-mail at mvaranvas@cdiassociation.com.

Take advantage of opportunities for personal growth

A clinical documentation improvement (CDI) specialists’ focuses  on educating physicians on the

Take advantage of educational opportunities where ever you find them.

Take advantage of educational opportunities where ever you find them.

merits and material benefits of complete, accurate, and effective medical record documentation on the practice of medicine. The CDI specialists’ goal is to affect positive change in physician’s documentation. CDI specialists also help the physician understand and appreciate his/her role in clinical documentation as a proactive and defensive strategy to meet the tough business economic climate challenge of healthcare.

In order to affect positive change and be successful in the role of CDI, the specialist need to view the duties and responsibilities inherent to the position through the eyes of a businessperson. Just as physicians are business people who happen to choose medicine as their line of business, CDI  specialists’ are business people who happen to choose documentation improvement as their line of business.

As a businessperson, the CDI specialists has the responsibility of expanding and continually building upon his/her business skills through personal investment in tools and education as a strategy in becoming more proficient and effective in the business of CDI. It is incumbent upon the CDI  specialist to maintain relevancy in clinical medicine through reading of the medical literature such as JAMA, New England Journal of Medicine, subscribing to Journal Watch publications, Mayo Clinic Proceedings, and other daily newsletters.

Other considerations include subscribing to the Harvard Business Review or Influence without Authority, and investing the time to refresh skills in negotiation and communication through coursework at a local college or adult education class.

A successful and competent CDI specialist will recognize the need for continual education beyond learning the basic CDI crash course taught and promoted by many consulting companies. The likelihood of success of a CDI program rests primarily on the CDI specialist, recognizing the value and worth of proficient business skills as a foundation for the delivery of physician clinical documentation education of long lasting benefit and use to both the institution and the physician.

Quite frankly, there is more to CDI than leaving clinical queries on the record in hopes of the physician answering the query. A CDI specialist can control his/her own destiny through development and honing of business, communication, and negotiation skills.

Let the opportunities begin.