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Restarting or revamping your CDI program: A case study
Catherine O’Leary, RN, BSN
& Colleen Garry, RN, BS
Agenda
Why do CDI programs fail?
The documentation team:– How to find and hire the “right” team– What tools and technology do we really need?– How do you retain your CDI team and keep them
motivated?– Question-and-answer session
The “program,” also known as: Clinical documentation “integrity”
Clinical documentation improvement
Concurrent documentation
Documentation enhancement
Compliant documentation
Other …
Why do CDI programs fail?
Some programs “fail” to see results and go by the wayside
– “We just sort of stopped doing it”– “No one held us accountable”– “We don’t know if it works or not”
Many programs lose momentum over time – “We just place worksheets on charts”
Why do CDI programs fail?
Staff turnover
Lack of “right” person in role of CDS:– “Do you know how hard it is to find nurses and
coders?”
Goals of program are not well-defined:– Revenue enhancement? CMI improvement?– Quality? Compliance?
Why do CDI programs fail?
CDS role is not dedicated to CDI:– “We have competing priorities —we have to get
the patient discharged first”
No “teaming” between HIM and CDS
Little or no tracking of results or sharing of information with CDS team:
– “No one ever shares these reports with us”– “We have tracking? Of what?” “How should I know
what the CMI is?”
Why do CDI programs fail?
Lack of physician buy-in: – “The hospitalists are great, but the surgeons?”– “We’ve been trying to get an advisor for years”– “The physicians don’t care—it doesn’t impact
them”
Lack of executive sponsorship
Why do CDI programs fail?
A well-defined daily process is not in place or the team is not following the agreed-upon processes
Lack of ongoing education plan:– “On the job training” (OJT) is not the best
approach– Materials are outdated– “We haven’t had any formal refresher since the
consultants left three years ago”
“Failure is not an option.”
—Jerry C. Bostick, flight dynamics officer (FDO), Apollo 13
Quote taken from the movie Apollo 13, directed by Ron Howard
Concurrent review—the team
Our preferred approach is use of a nurse “documentation specialist,” who teams with the coders in HIM
Nurses use clinical expertise and critical- thinking skills when reviewing the entire medical record to formulate the query for more specificity in physician documentation.
Concurrent review—the team
HIM professionals provide the coding expertise and compliance oversight
Care management involvement to include assessment criteria for medical necessity
Physician/medical advisor key member of the team
Concurrent review—the team
Other approaches that work include HIM specialists, physician coaches, and use of case managers
Should be customized for the individual client situation, such as resource availability (coders, nurses in shortage) and/or size of facility
People
People: Finding and hiring
Do we need to hire?
Where do we find these nurses?
How do we know if they are “right” for the job?
What skill set should we look for?– Coding? Clinical expertise? – Case management or utilization review?
People: Do we need to hire?
Assess current staffing:– Simple rule of thumb = 1 CDS / 2000-2500
discharges– Will we look at all payers?– Have we had turnover?– Are there other internal resources we can use,
such as concurrent coders?
People: Where will we find them?
Recruitment efforts:– Making the job description attractive and accurate
… compete for the best– Flexible hours—Maximize coverage (i.e.,
10-12–hour work days or part-time job shares)– Recruitment agencies
What’s negotiable with limited resources available?
Learned “experience”
People: The “right” person
Screening criteria: Key attributes:– Strong, recent clinical skills – Critical-thinking ability– Interpersonal skills– Ability to “read between the lines”—not always
black and white– Understanding of coding guidelines–a “bonus,”
but not necessary for hire
People: The job interview
Questions to ask:– Behavior-based interview questions– If nurse is not coming from bedside, how does
he/she keep “current” with clinical practice?– Provide candidate with some clinical scenarios—
ask for clinical signs/symptoms– How would candidate handle a challenging
interaction with a physician?
People: What skill set?
Clinical expertise over chart review experience?
Particular clinical specialty?
Presentation skills:– Ask clinician to provide a short presentation: 5–
10 minutes on any subject to assess presentation skills; will be your ongoing documentation “educators.”
Process
Process: Training/retraining
Orientation
Timeline
Evaluation of staff—assessment of skills and “learning curve”
How to know it’s not working for the CDS and/or the team
Process: Daily activities
Workloads, work lists and assignments
Tracking results:– Automated vs. manual– Simple vs. sophisticated
Revisiting the agreed upon “process” on a regular basis, including the coders in the process
Process: Training/retraining
Ongoing retention plan—and master education plan
– How will we train new staff?– How often will we use outside consulting
expertise?– Will we send our staff to educational forums?– Involvement in ACDIS? Expectation for “certified
CDS” staff?
How to enhance the role of CDS
The mature CDI program
Expansion of role
Established CDS team becomes your in-house documentation “experts,” working in collaboration with HIM for coding expertise
Collaborate with utilization nurses for “medical necessity” criteria and case management on “length of stay”
Expansion of role
Include a CDS on the EMR team
Include a CDS on the RAC audit preparedness team
Include a CDS on the quality committee—for integration of some core measure criteria, P4P, POA
Engage the CDS team as ongoing internal auditors
Expansion of role
Encourage CDS team to proactively seek out training opportunities within the hospital—providing in-service training on a regularly scheduled basis, especially with physician staff
Get to know your “top 10 MS-DRGs”
Utilize CDS team for report interpretation and assessment of results
Expansion of role
Encourage CDS to get involved with ACDIS or local meetings
Encourage CDS to sit for certification—compensate for completion
Involvement with AHIMA or HFMA
Questions
Speakers Catherine (Cari) O’Leary, RN, BSN, is the managing director and founding
partner at CSG Health Solutions, LLC. O’Leary has more than 23 years of clinical and healthcare experience and has been involved in the documentation improvement arena for the past 12 years. She lives and works in the New York metropolitan area and has been involved with clients “hard hit” by the RAC demonstration project and she speaks nationally on the subject. Her firm has been engaged recently by a large number of clients looking to restart or revise their CDI program. O’Leary can be reached at [email protected].
Colleen Garry, RN, BS, has been involved in clinical documentation since 2005. Prior to joining NYU Langone Medical Center, Garry developed, implemented, and sustained a very successful program at the Medical University of South Carolina. She is now involved with program re-implementation. A majority of Garry’s nursing career has involved new program development in various clinical areas. She is on the steering committee for UHC’s Clinical Documentation Project. She is the author of The Clinical Documentation Specialist’s Handbook and has authored many articles pertaining to the specialty. Garry serves on the ACDIS advisory board.
