Note from the Associate Editorial Director: Consider the peer audit

By Melissa Varnavas

Back in 2015, 40% of ACDIS Radio listeners (of the October 28, 2015, broadcast) indicated their CDI program had an established query auditing process in place. Another 29% said they had some type of query review practices established but they only informally or occasionally take the time to examine the efforts of CDI specialists.

ACDIS has long advocated for some type of regular query practice audit and review—be that driven by the CDI program manager or director or peer-to-peer amongst the CDI team. Donald A. Butler, RN, BSN, then the CDI manager at North Carolina facility authored a White Paper regarding the auditing process and provided an in-depth PowerPoint presentation regarding the benefits back in 2012. In 2013, a number of professionals described the importance of such reviews and pulled the lid off for a glimpse inside their own processes in a CDI Journal article.

“Every profession that exists has some form of peer review processes,” said Donna Kent, RN, BSN, CCDS, a CDI manager in California, at the time. “Healthcare is no different. CDI programs should be no different either.”

It’s not that hard to start.

First, make sure you have query policies and processes formalized. If you don’t have a query policy, check out the “Resources” tab and look under policies and procedures. Make sure you have copies of the latest Guidelines for a Compliant Query Process beside you as you amend those samples and make them your own. Vet your policies with your HIM and compliance counterparts to make sure you’ve not included any instructions which might be later deemed risky or non-compliant.

Next, provide the policies and procedures to the CDI team and coding staff and have a round table discussion about them. Allow the team to ask questions about the processes and to offer their insight and expertise about how to best implement the policies. Do incorporate any worthwhile suggestions made during these sessions but double check again with HIM and compliance before implementation.

During the implementation stage, you’ll want to review the policies with the staff again, thank them for their earlier input and explain that everyone will now be expected to adhere to these standards.

Now, with the policies in place, you’ll be ready to collect some information and begin your audit processes. Leverage those policies of yours into a review checklist. A standard form used by all staff makes the effort less subjective. (Click here to download a sample donated to ACDIS in 2015 from Karen Chase.)

Your checklist should include specific questions related to your query policies and include principally “yes,” “no,” or “not applicable” responses. Adapt the checklist as needed, as you the focus of your audit changes (purely query compliance, accuracy of outcomes data, or analysis of the entire CDI program). In the beginning, however, start with a small, concentrated focus to support the long-term auditing efforts—items such as “is the query leading,” or “what type of format did the CDI reviewer use for this query.”

Randomly select 10-15 charts from each CDI staff person and provide each member of the team with a random sample of co-workers’ charts. Make sure the charts that staff review are random, said Butler in that 2013 article, so that a good cross section of queries can be examined. Audit queries for representation of disease types and representation of query reasons (e.g., specificity, legibility, lack of diagnosis). If you have a big enough CDI team, you may want to pair up staff so each record gets two reviews to establish inter-rater reliability. And if there is disagreement on a case, have the team turn over the record to the CDI manager.

The reason for auditing isn’t a simple exercise for staff. These reviews should serve as mentoring and collaborative sessions allowing experienced staff to offer their insight to those newer to the role and to provide a safe environment for teammates to take the best aspects of each other’s record review practices and incorporate them into their own efforts. Although peer reviews should never be implemented in a punitive manner, data collected over time and reviewed by the program managers can illuminate opportunities for education, re-education, and review targets to improve the overall program.

Editor’s note: Varnavas is the Associate Editorial Director for ACDIS and has worked with its parent company for nearly 12 years. Contact her at mvarnavas@acdis.org.