Guest Post: Take your program from good to great by getting back to basics
by Fran Jurcak, RN, MSN, CCDS
So you’ve been trudging along with your program; the numbers look good to fair, and when you speak with physicians they seem to understand the bigger picture but you know your program could be better. So how do you “shock” it back to life? Usually it’s a matter of stepping back and taking a look at the global picture of what’s happening within your facility and within your team.
There are a number of issues that you may need to address but the one of the first may be to evaluate your process to determine:
- When records are reviewed?
- How are queries communicated?
Process improvement is always a moving target. To stabilize that target you need set a clear goal and make sure every aspect of CDI program moves toward achieving that goal. Assuming the goal is accurate and specific documentation of the true severity of illness (SOI) of each patient, then ensuring that all conditions being evaluated and treated appropriately should be the driving force for the process. The role of the CDI specialist in this process then is to serve as a resource to providers to support the goal of accurate documentation.
Due to Official Guidelines for Coding and Reporting and guidance published in the American Hospital Association’s Coding Clinic for ICD-9-CM, the CDI Specialist must ensure that the documentation is clear and consistent throughout the medical record. Therefore the sooner a record is reviewed, the greater the opportunity to impact the clarity and consistency throughout the patient’s hospital stay. Therefore, review of the medical record should begin within the first 24-hours of admission.
Clearly the CDI Specialist needs to allow the provider an opportunity to assess the patient and provide some initial diagnoses in the record but once that initial history and physical has been documented it’s vital to get into that record. Here’s the opportunity to validate present on admission (POA) diagnoses as well as clarify specificity of acute conditions and define diagnoses that were the cause of the admitting signs and symptoms. Initiating queries to ensure that these conditions are documented early in the patient’s stay ensures that we will capture POA diagnoses and also serves to nail down principal diagnoses. The sooner documentation is clarified the more consistently it can be documented throughout the record.
If there is the opportunity to clarify documentation, getting that information to the physician becomes an important action in the CDI process. Leaving paper queries is a common practice however not always the best way to get a positive response. Face to face interaction still proves best as it allows the CDI specialist to educate the provider, answer physician questions, and re-phrase the query as needed for enhanced clarity. Personal interaction seems to allow the provider to feel a sense of teamwork rather than feeling like they are being monitored and judged for their documentation missteps. Many CDI specialists have seen their physician response rates increase when they refresh their programs with a return visibility on the patient units.
In summary, sometimes the obvious steps can become a driving force for change. If a CDI specialist isn’t in the record early and often than the opportunity to impact documentation becomes limited. Thus, a quick and easy method to jolt your program back into reality is to go back to basics. Be visible, be available, and get quickly into the record to maximize opportunities and minimize retrospective work.
Editor’s Note: Fran Jurcak, RN, MSN, CCDS, at the time of this article's original release, was a manager with Wellspring Partners, a division of Huron Consulting, and had been a nurse for 25 years. She has a strong clinical and educational background having served as a professor of nursing for many years. She was currently active in several professional associations directed at revenue cycle and documentation management.