Column: Involve physicians in CDI program effort to enhance buy-in

March 31, 2011

By Vickie Balistreri, BA, RHIA, CCS, CCS-P, CCDS, CPC, CPC-H

“Tell me and I’ll forget. Show me, and I may not remember. Involve me, and I’ll understand.”

I often think about that adage when attempting to educate physicians about CDI efforts. One of the most challenging and yet fulfilling aspects of the CDI specialist’s role is to have physicians not only understand why we need better documentation but see them become motivated and involved in documentation improvement.

One thing I’ve learned in the many years working with physicians is that you have to love what you do— it really does show! You have to be a little passionate and have a lot of patience and persistence to truly involve the physicians in understanding the importance of complete and accurate documentation in the medical record. Just as in any relationship, it is important to be easy to talk to and be there, be visible.

Physician documentation not only paints a picture of what is going on with the patient, but is a reflection of the quality of care physicians are providing. Complete and accurate physician documentation also accurately portrays the severity of illness, as well as risk of morbidity and mortality.

Quality is being measured in many different ways by different organizations and is visible to not only the physicians but patients, insurance payers, CMS, and can be found on various healthcare websites and physician profiles. CMS has stepped up quality initiatives to measure and monitor specific core measures, patient safety issues, and hospital acquired conditions. Physicians are being scrutinized by payers who use physician profiles to weed out physicians who profile poorly due to lack of accurate and complete documentation.

Physician documentation demonstrates quality of care in various ways, such as:

Legibility: Can other healthcare staff read the physicians orders? If not, patient care could be compromised.
Hospital acquired conditions: Were conditions present on admission or did they develop after admission?
Reason for admission: Is it clearly documented and does it support medical necessity?
Specificity of diagnoses: Are diagnoses clearly documented with the appropriate level of specificity?
Rationales: Are treatment rationales clearly described and the impact on patient care clearly documented? Do the diagnoses in the chart support the procedures, treatment, and monitoring performed?
Patient response: Is patient’s condition improving, resolving, worsening, etc.? Has the physician documented the patient’s progress?
Treatment changes: If there are changes in treatment such as change in antibiotics, has the physician clearly documented his/her clinical rationale?
New developments /complications: Anything can happen in a hospital and treatment of the condition that warranted the admission of the patient can quickly involve treatment of other comorbidities. If there are new developments or complications affecting patient care and length of stay are they clearly documented?
Medical necessity for continued stay: Is it clear why the patient is still in house?

Although there are many different ways to involve physicians in CDI efforts, one of the best is to have a one-on-one conversation with the physician stressing that the quality of their documentation reflects the quality of care they provide. Some physicians are very receptive to peer-to-peer education, such as having a physician provide documentation improvement education. Some physicians like to be taught in a group setting by specialty; for example, involve your nephrologists to discuss acute tubular necrosis documentation. (See the physician education section of the Forms & Tools Library for an acute kidney injury documentation tip sheet.)

It can be a struggle to get physicians to attend a group meeting or get their attention. Ask physicians which method they prefer, be flexible and willing to try different methods. Some suggestions include:

Present a “documentation tip of the month” at the monthly medical staff meeting
Have a CDI-supportive physician discuss a specific documentation topic during a regularly scheduled physician meeting
Provide educational materials in places physicians frequent such as the physician lounge
If your facility publishes a physician newsletter, include a regular section on CDI tips on a topic of particular concern (e.g., malnutrition,acute kidney injury)
Distribute documentation pocket cards as reminders; some physicians like these
Enlist the assistance of the compliance department by requiring physicians to attend an annual documentation training session as a part of fulfilling compliance education (training on proper documentation and coding is encouraged by the OIG and will reduce risks of False Claims Act penalties)

The key to success is flexibility and the willingness to try different ways to engage physicians. Having a physician champion is so very important as well as having the support of administration such as the medical staff director, chief financial officer, and chief executive officer.

Complete and accurate physician documentation is important for many different reasons; one of the most important is its reflection on quality of care. Diligence, patience, and persistence in trying different ways to teach by “telling,” “showing,” and “involving” physicians will help your CDI message take hold. Believe me, when a physician understands CDI efforts it can be worthwhile and rewarding.

Editor’s Note: Vickie Balistreri, BA, RHIA, CCS, CCS-P, CCDS, CPC, CPC-H, is an consultant with JA Thomas & Associates, based in Kansas City, MO. Contact her at 816/645-7721 or by e-mail at vbalistreri@sbcglobal.net.

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