core measures
Our VP of Nursing is hinting around to our director that maybe the CDI team should take over the responsibility for core measures. I would appreciate input from my colleagues if you are doing this or did it in the past? I heard from a neighboring CDI specialist, they did it for awhile but did not get to all of the records fast enough for some of the standards e.g. ASA within 24 hrs of an MI. If you are doing this, do you have just a piece of it or the whole responsibility? I recall from a demonstration that JA Thomas has a specific module for this built into their software, do other systems have the same?
Do I sound a little panicky how to pull this off??!!
I am 'invited' to a meeting Monday afternoon to present our view and would be forever grateful for some insight into developing a process.
Thank you very much - Linnea
Linnea Thennes, RN, BS, CCDS
Supervisor, Clinical Documentation Improvement
Centegra Health System
815. 759-8193
lthennes@centegra.com
Do I sound a little panicky how to pull this off??!!
I am 'invited' to a meeting Monday afternoon to present our view and would be forever grateful for some insight into developing a process.Thank you very much - Linnea
Linnea Thennes, RN, BS, CCDS
Supervisor, Clinical Documentation Improvement
Centegra Health System
815. 759-8193
lthennes@centegra.com
Comments
That being said, our contribution as CDIs is very valuable: I include core measure reminders on all my Progress Note Queries for Core Measure Diagnoses, I include Core Measure information in every presentation I do, I always include Core Measures when I chat with Physicians and other staff. Without the dedicated staff to focus on Core Measure Diagnoses first, and certainly without an automated process where charts with Core Measure Diagnoses are pre-identified and flagged for you; I just do not see how CDI can be responsible for it over a Quality Department.
Kindest Regards,
Mark
Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Clinical Documentation Excellence
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital
Information Technology
5255 Loughboro Rd NW
Washington DC, 20016-2695
W: 202.660.6782
F: 202.537.4477
mdominesey@sibley.org
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http://www.sibley.org
meeting the criteria, we will gently remind the RN staff to review the
chart and consider implementing the Core Measure Process - however, Core
Measures is not one of our prime duties. We are understaffed and we do
not see all cases with a 24 hour period. I think CDI staff 'could'
perform Core Measures, but only if allowances would be made in terms of
staffing and work flow.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
not addressed, I will query, but it's not on my "to do" list. Quality
follows those here. I consider myself a helper with regard to this.
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"We are dealing with Veterans, not procedures; With their problems, not
ours." --General Omar Bradley
Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
I'll emphasize again, be careful about having this as ANYTHING more than a task where you agree to help out. If it becomes a core responsibility (even if shared) and/or high priority, will have an impact on workflow, productivity, etc. Very likely to see declines in CDI metrics. Would absolutely need to explore what this would mean as far as staffing levels.
Finally, there would also need to be some solid education -- active abstracting for core measures is quite different from CDI (passive abstracting from the documentation). There is a given & firm set of definitions that need to be complied with (and understood). There is not the requirement to rely on physician documentation. In fact, there will be cases that identify for core measures that will not be reflected in the final coding data base. The reverse is also true. Two primary examples that we've encountered are VAPs and CAUTIs. Physicians with VAP in particular document a link where the quality staff rule out the VAP based on their definition. The opposite is often the case for CAUTIs, the physician doesn't establish the link but quality scores as a CAUTI.
Don
Vivian
Kim Digardi, RN
Documentation Integrity Specialist
St. Helena Hospital
10 Woodland Road
St. Helena, CA 94574
Phone: 707.967.5936
Email: digardsk@ah.org
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
srcole@phn-waco.org
Sally Lamberson, RN
Clinical Documentation Specialist
Case Management and Discharge Planning
Direct: 303-938-3352
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of distracting from the very detailed and labor intensive work that a
CDS has to do is not a good idea. The fact that you are "in the chart"
does not justify reducing your effectiveness both for reimbursement and
SOI/ROM.
Donna
Donna Kent, RN, BSN, CCDS
Manager, Clinical Documentation Integrity Program
Clinical Quality and Accreditation
Torrance Memorial Medical Center
ph.:310 784-6884 fax:310 784-6899
donna.kent@tmmc.com
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presentation, in one on one conversations with physicians and in=20
educational posters. However, it is not the responsibility of a CDI nurse =
to review=20
for Quality Measures. There is enough for the CDI nurses to review in just=
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capturing the most appropriate severity of illness and risk of mortality.