CDI Week 2021 Q&A: A full menu (productivity)

As a preview of the eleventh annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. These Q&As will continue throughout CDI Week, September 13-17 as well. Gail Weldon, RN, CCDS, CDI team lead at Baptist Medical Center East in Montgomery, Alabama, and at Prattville (Alabama) Baptist Hospital, answered these questions. She is a member of the ACDIS Certification Committee and of the 2021 ACDIS Furthering Education Committee. For questions about the committee or the Q&A, contact ACDIS Editor Carolyn Riel (criel@acdis.org).

Q: This year’s CDI Week Industry Survey includes questions on productivity for the first time. (ACDIS’ last look at productivity “Set CDI productivity expectations, but don’t look for a national standard” published in 2016.) Why do you think it is important for information like this to be gathered and made available? Why is it important to know how your CDI department (as well as yourself as a CDI professional) compares to national averages?

A: CDI is an ever-growing industry with changing expectations for focus and performance. I believe it is important to know what the national average is. No program will be exactly like another. The types of facilities are different—such as a trauma center versus a community hospital—so the data should be used not to compare but to enhance your CDI program performance goals.

This information can be used to evaluate individual departments to address areas that may have opportunities. If the productivity is below the national average, is there an opportunity to improve? If productivity is well over the national average, are the reviews impactful? Opportunities to improve impact are at the forefront of most CDI programs and this data may help find places where there are educational opportunities for the CDI specialist, restructuring worklists to better meet your needs, and other benefits.

Q: Most respondents (57%) say they review an average of six-10 new records per day—with roughly the same amount (54%) say management expects them to perform six-10 new reviews per day. Being that a similar percentage of respondents say their expected and actual chart reviews per day are in this range, do you think these ranges for new reviews per day are good standards for the CDI industry to hold? Are there risks with having set standards for productivity for the CDI industry as a whole?

A: Setting standards needs to be carefully considered. I believe most CDI specialists are self-motivated and driven to excellence. If standards are set too strenuously, the focus for the CDI specialists may change to individual performance. As a CDI profession, we are reviewing records for integrity and quality of documentation. Therefore, if focused on individual performance, the CDI specialists may miss opportunities to clarify the documentation in order to meet expected productivity goals.

The review goals should be set by the individual program. When defining the goals, the following should be taken into account:

• What is the population’s severity of illness at the facility?
• Is the assignment made by service line, priority score, random assignments, etc.?
• What is the existing CDI specialist workforce?

A direct correlation between number of reviews and query opportunities can sometimes be seen. Some CDI specialists review fewer reviews but have a greater impact with their queries, while others that perform a high level of reviews, but have a lower query impact. Other CDI specialists review more records as well as show a great impact with queries. It is good to recognize your CDI staff’s individual strengths and weaknesses, so that the productivity can be managed appropriately.

Q: Only 6% of respondents noted remote work due to COVID-19 decreased their productivity. What effects, if any, did your CDI program see in terms of productivity related to the pandemic? Has your CDI program returned a pre-pandemic “normal” now? What changes did your organization implement related to CDI during the outbreak that it intends to maintain going forward (if any)?

A: Our organization, like so many, sent most of the CDI staff home in March 2020. We took our work computers and monitors home and set them up in our home offices. We have two CDI staff members who requested to continue to work at the hospital and they were moved to the same facility.

Our workflow did not change. Assignments were made as usual; reviews and queries were done the same way, so we did not see a decrease in productivity. We were already using message center in our EHR for all provider correspondence, so the move went smoothly. We did not see a dip in query responses since we had not changed the query process.

Our productivity remained the same for some and went up for others. I personally feel that I have become more productive because there are fewer interruptions during the day. As team lead for two of our facilities, I am able to communicate in several ways with the staff. We use instant messages, office email, and of course our cell phones. We have the phone numbers to the nursing units and to the physician dictation areas at all of the facilities to be able communicate in a timely manner.

Our organization made the decision to keep our CDI team permanently remote and there is no plan to bring us back into the facilities. The two CDI that remain in-facility can change to remote when they’re ready. Since we are remote, we have been able to keep all of our staff. The staff members that moved away from the area were able to stay on staff and we now have staff living in three states. This has kept continuity in our processes as well as strong experienced CDI on our team.

Because we are no longer face to face with the providers, our CDI team felt it imperative that we create a good orientation process for new provider’s onboarding. The CDI team has worked to create a process for provider virtual orientation. We have created a PowerPoint presentation to explain the CDI process at our organization, introducing our staff, providing our phone numbers, educating the provider in the query process, and giving them documentation tips on our highest queried diagnoses. We give them a packet with a welcome letter, copy of the PowerPoint, pocket tip cards, and one of our CDI ink pens. We have two medical resident groups at the larger of our facilities and we provide an orientation for them as a group each year.

Q: A large portion of respondents mentioned not having certain technological solutions (52% do not have a quality database, 51% do not have computer-assisted physician documentation, 42% do not have internally developed EHR modifications, etc.). What role do you think technology plays in CDI productivity? Do you feel technology is an aid or hindrance to productivity? Why? How does technology affect productivity in your facility?

A: We use a software solution with a prioritization function to assign patients. We had a paper process when our CDI department was created in 2012 and have since been given new solution to make the process much easier. We began to use the prioritization tool around the first of this year and most of the staff have become comfortable with it. We began prioritization in 2021 only doing concurrent reviews of Medicare, Medicare HMO, Champus/Tricare, and Blue Cross Blue Shield.

In May 2021, we went to an all-payer model, and we are using the prioritization to ensure we review those records with the most opportunity to impact.  As a group, our CDI specialists hate to leave any patient unreviewed and it has been a challenge for some to change that routine. We do not have an automatic process for nudges to the physician and we send queries in the message center of our EHR as needed. I believe that CDI technology is a wonderful tool to use in capturing opportunities but does not take the place of a CDI specialist’s critical thinking skills.

Q: More experienced CDI staff are more productive, according to survey respondents, 62% of whom noted that the experience of the reviewer had the largest effect on CDI productivity. What steps can a CDI professional take to increase their experience and therefore improve their productivity? How long do you think it should take a new CDI specialist to become proficient in their role? In your opinion, can one-on-one staff mentoring, or CDI/coding collaboration, improve a CDI specialist’s record review capabilities?

A: I definitely believe the more experienced the CDI specialist is, the more productive he or she should be. Most of our original CDI team is still in place and we have added four new CDI staff members. The original team came from case management, quality management, surgery, and coding. We were given a course on coding and sent to the floors to read the paper charts. Our first queries barely scratched the surface of what we do now, but that took time to learn.

Learning how your providers think and what they respond best to takes time. Add to that learning about disease processes, abnormal diagnostics, etc., while learning a new computer program makes the new CDI less productive. A new CDI specialist that is the best beside nurse in the world has a learning curve in what can be a principal diagnosis, a CC, an MCC, what in the world makes severity of illness/risk of mortality scores, and don’t forget the hierarchical condition categories.

A new CDI specialist that is a great coder has a learning curve on the clinical side of understanding disease processes. I think it takes a good year or more to become proficient and one-on-one staff mentoring is an excellent way to help that process.

I believe in fostering a good relationship between the CDI specialists and the coders. In orientation, I feel the new CDI specialist should sit with an experienced coder for a day or more to begin to see the world of coding. Reading it in a book is not the same as watching the coder work a chart. There are so many coding guidelines, conventions, and Coding Clinics that it can be mind boggling to the novice CDI professional. Only learning from an experienced coder and an experienced CDI specialist help the new CDI to be able to understand this new world he or she has stepped into.