TBT: Finding a definition for failed CDI programs

by Donald A. Butler, RN, BSN

Years ago, I started a conversation on CDI Talk (now the ACDIS Forum) about failed CDI programs, hoping at the time that there might be someone willing to divulge a first-hand account of how and why their program “failed” and perhaps how they were able to “save” or “reinvent” it.

While discussion generated quite a bit of conversation (there were upwards of 36 responses at the time), and helped me realize there is not a clear definition for what might be considered a “failed program” in the first place.

It’s a sensitive subject. Revealing serious struggles might imply shortcomings or perceived shortcomings about a present program and not some previous or anecdotal one. In my (humble) opinion, however, recognizing program problems can help us seize a genuine “opportunity for improvement.”

Better than finding potential success amidst the rubble of insurmountable obstacles for an individual program, is the possibility that together we can all learn something from each other’s schools of hard knocks.

Before we can consider failures, maybe we should outline what the industry has come to view as CDI program standards and basic functions. Consider these two quotes from the AHIMA Guidance for Clinical Documentation Improvement Programs (May 2010):

“The focus of most CDI programs is on improving the quality of clinical documentation regardless of its impact on revenue. Arguably, the most vital role of a CDI program is facilitating an accurate representation of healthcare services through complete and accurate reporting of diagnoses and procedures.”

And:

“A successful CDI program can have an impact on CMS quality measures, present-on-admission conditions, pay-for-performance, value-based purchasing. The documentation in the medical record becomes data that is used for decision making in healthcare reform, and other national reporting initiatives. Improving the accuracy of clinical documentation can reduce compliance risks, minimize a healthcare facility’s vulnerability during external audits, and provide insight into legal quality of care issues. In a successful program, the CDI professional works to facilitate the overall quality and completeness of clinical documentation to accurately represent the severity, acuity, and risk of mortality profile of the patient being treated.”

I also encourage review of the ACDIS White Paper “What Every CDI Program Needs to Succeed is Structure, Staff, Process,” by Lynne Spryszak, RN, CCDS, CDIP, a CDI specialist at Acuity Delivery Systems in the greater New York City area.

So, without further ado, here are some thoughts I had on defining “failed” or “under-performing” CDI programs.

A “failed” program is one which:

• Completely ceases to exist due to:
  • Elimination or cancellation by the organization either as a cost saving measure or perceived/actual lack of performance of the program.
  • Staff departures, which prevent long-term viability/sustainability. This might reflect a program where success is based on individual performance rather than on the CDI process. Also, smaller programs are likely at higher risk where the loss of one or two team members can eliminate the program’s “institutional memory.”
  • Lack of sufficient staffing where the devoted resources are inadequate or not supported.
  • Some fault or error surrounding initial implementation, program design, or inadequate support.

• Significantly misses performance targets (or metrics) where
  • Targets are undefined and/or internal benchmarks are not established
  • Metrics are not rigorously reviewed for accuracy, shared, and/or applied to maintain focus and potential growth
  • Targets are unrealistic (may be either internally set or established by consultants)
  • Metrics are focused primarily on financial impact
  • Metrics are appropriate but goals and findings are not shared with CDI specialists
  • Benchmarks and reporting are efficient but findings are not used as tools for CDI staff or physician education and feedback

• Cannot withstand audit scrutiny such as:
  • Whistleblower suits similar to those levied against UnitedHealth Group recently
  • RA, MAC, MIC, CERT reviews

• Lacks medical staff engagement, collaboration, and support due to:
  • Ineffective communication of the CDI program mission
  • Lack of administrative support that encourages medical staff partnership in the CDI program.
  • Uncooperative medical staff/organizational relationship

• Has been deemed to have failed by an external (consulting) group due to:
  • Analysis of performance, metrics, or focus (based on the consultant’s standards); the program from the consultant’s perspective doesn’t measure up
  • A change in consulting relationships from one firm to another, especially where there are differing philosophies and goals
  • A change in CDI program focus

Editor’s note: This article originally appeared on the ACDIS Blog on June 6, 2011. It has been updated to reflect the current CDI landscape.