Restarting or revamping your CDI program: A case study

2. Restarting or revamping your CDI program: A case study Catherine O’Leary, RN, BSN & Colleen Garry, RN, BS

3. 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

4. The “program,” also known as: • Clinical documentation “integrity” • Clinical documentation improvement • Concurrent documentation • Documentation enhancement • Compliant documentation • Other …

5. 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”

6. 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?

7. 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?”

8. 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

9. 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processes • Lack of ongoing education plan: • “On the job training” (OJT) is not the best approach • Materials are outdated • “We haven’t had any formal refresher since the consultants left three years ago”

10. “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

11. 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.

12. 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

13. 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

14. People

15. 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?

16. 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?

17. 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”

18. 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

19. 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?

20. 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.”

21. Process

22. 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

23. 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

24. 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?

25. How to enhance the role of CDS The mature CDI program

26. 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”

27. 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

28. 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

29. 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

30. Questions

31. 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 coleary@csg-hs.com. • 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.