Feature: Set and assess core competencies continuously

February 8, 2016

CDI Blog - Volume 9, Issue 8

by Sylvia Hoffman, RN, CCDS, CCDI, CDIP

The job description for a clinical documentation improvement (CDI) specialist involves more than simply leaving queries. The role takes many different forms, however, standard competency elements do exist—competencies CDI staff must achieve in order to perform their job well. A CDI supervisor, or other department head, needs to determine whether his or her CDI team is functioning properly and upholding these standards.

However, standard competency elements do exist—competencies CDI staff must achieve in order to perform their job well. In 2014, the ACDIS Advisory Board created a position paper outlining its recommendations for CDI standards, titled Defining the CDI Specialist’s Roles and Responsibilities. A CDI supervisor, or other department head, needs to determine whether his or her CDI team is functioning properly and upholding these standards.

In my opinion, one of the most important skills for a CDI specialist is the ability to read the medical record and identify where incomplete, unclear, inconsistent, or missing documentation exists. This requires a firm knowledge of medical indicators and medications, as well as an understanding of medical reports. The CDI specialist must also have a basic knowledge of coding conventions, the Official Guidelines for Coding and Reporting, and the AHA’s Coding Clinic for ICD-10-CM/PCS.

It is equally important for CDI program managers to regularly assess their CDI team on a transparent set of basic statistical measures to determine their effectiveness on both individual and departmental competencies. Many hospitals measure the following for their CDI specialists:

Record review rates
Query rates
Query answer rates
CC/MCC capture rates

In 2010, AHIMA published a paper titled Guidance for Clinical Documentation Improvement Programs as well as its “Clinical Documentation Toolkit.” The “Toolkit” stated:

CDI programs can be staffed by nurses or other clinicians who may be unfamiliar with the standards applied to coders, and that since CDI is still a relatively new program, it is important for facilities to have a system of checks and balances in place to ensure a high level of integrity.

These basic measures of success, however, may not be enough to determine if a CDI staff member is competent in his or her day-to-day role. Documentation specialists should be monitored and tested on a periodic basis to determine their professional knowledge and skill sets.

Depending on the type of orientation and training they receive, and the ongoing education provided, CDI specialists (and the departments they work in) can either flourish or flounder.

Editor's Note: This article is an excerpt from the January/February edition of the CDI Journal.

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