CDI Leadership
Good morning. I have a few questions to pose surrounding your CDI program. Grab some coffee!! It is deepdive Wednesday:)
1. Do you have a static staffing ratio per unit or do you staff by the census?
2. How do you recruit, select, and coach staff? What is your retainment and turnover like?
3. Do you have any efforts to increase the number of BSN nurses?
4. Given that physicians are often times a diverse culture and one of our larger stakeholders for CDI, do you have a role in developing culturally competent CDI?
5. Do you use evidence based criterias for your query process?
6. Lastly, do you incorporate a specific theory for your practice?
I appreciate all your feedback!
Kathy Shumpert, RN, CCDS
Community Howard Regional Health
kshumper@communityhoward.org
1. Do you have a static staffing ratio per unit or do you staff by the census?
2. How do you recruit, select, and coach staff? What is your retainment and turnover like?
3. Do you have any efforts to increase the number of BSN nurses?
4. Given that physicians are often times a diverse culture and one of our larger stakeholders for CDI, do you have a role in developing culturally competent CDI?
5. Do you use evidence based criterias for your query process?
6. Lastly, do you incorporate a specific theory for your practice?
I appreciate all your feedback!
Kathy Shumpert, RN, CCDS
Community Howard Regional Health
kshumper@communityhoward.org
Comments
trying to recruit CDI's which are extremely hard to do in this region. I
think the questions you have posed are good points to consider in any
program. We do not just recruit BSN, and they would most likely get
compensated the same as a new CDI. Culturally diverse, well our team of
two already has that which is a wonderful advantage. Evidence based
criteria queries.. we are not there yet but wonderful idea!
I love CDI talk.. I learn so much. Everyone have a great day!
Jamie Dugan RN
Clinical Documentation Improvement Specialist
Baptist Health System
office:904-202-4345
cellular: 904-237-7253
Business Email-jamie.dugan@bmcjax.com
cdis.icd10@bmcjax.com
Our program is 5 years old now.
Basically, when an opening comes up, they seek nurses with either a coding or case management background.
The entire hospital is on the magnet journey so there are specific mandates related to achieving the BSN however we do not hire based on BSN vs. associates degree nurses.
Our queries are evidence based.......as far as our hospitalist and MD's. Yes we are culturally diverse however we do not have a specific program for development. We do however spend a great deal of time on the units and offer education to all of our physicians.
We only have 4 CDI's for two campuses so we basically divide up the hospital........we have a priority routine of new cases first, query cases second and then re-reviews.
Our basic theory for our practice,,,,,,,,,,is "git it done"
Lisa Romanello, RN,BSN,FNS,CCDS
CDI Specialist
CJW Medical Center
Chippenham Campus
804-228-6527
a. We staff by unit. Each CDIS has 2 units. If someone finishes their units, they call around to see who needs help. Everyone enjoys working together so I have not had any problems with people slacking.
2. How do you recruit, select, and coach staff? What is your retainment and turnover like?
a. Living in a small city, we don’t have CDI Specialists except the ones we train. We prefer Coding Professionals or RNs with Case Management experience. I’ve been in CDI for 4 years and have had 6 different co-workers. The Coding Professionals all leave to go work as coders from home and the nurses all left for various reasons – mainly for higher paying jobs or supervisory positions. Right now, besides myself, I have a nurse who’s been here for 3 years, 2 that have been here for 1 year, and a coder that started about 6 months ago.
3. Do you have any efforts to increase the number of BSN nurses?
a. Our hospital has said everyone needs to get their BSN and in a couple of years plan to only hire BSNs. 2 of my nurses already have their BSN, I will graduate in 2013 with mine. My other nurse says she’s of an age that she is not going to mess with it. But she is going to sit for the CCDS in the next few months. (2 of us have our CCDS, and 2 will be sitting for theirs in the next few months). My coder has her CCS & college A&P, but I think she still has to wait 2 years to sit for the exam).
4. Given that physicians are often times a diverse culture and one of our larger stakeholders for CDI, do you have a role in developing culturally competent CDI? The physicians who have agreed to CDI training received the basics and specialty training - most of those got 1:1 with me after I reviewed 10 of each of their records. Our annual hospital review hits on cultural diversity, but we don't single out any one culture and determine training based on that.
5. Do you use evidence based criteria for your query process?
a. We have not had any luck getting physicians to give us their own personal criteria for specific diagnoses, so we use the live and learn model – ie: this one yelled at me for 30 minutes that ____ doesn’t meet his idea of ____, so we incorporate that into our query practice.
6. Lastly, do you incorporate a specific theory for your practice?
a. Our specific theory is whatever works best. I have no qualms at all in sending one specific CDI Specialist who seems able to get a certain difficult doctor to address queries, etc.
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
Sharon.cole@phn-waco.org
1. We have a BSN CDI team at the present. We review based on unit, service, and payer though not necessarily in that order. Our policy is to see ALL patients regardless of payer but we actually see only 15-20% of all inpatients and 45% of Medicare.
2. We recruit from in-house and send all newbies to CDI Boot Camp.
3. We presently have 3.6 FTE. I am in the process of approaching Senior leadership about the addition of 1 more FTE.
4. My goal to develop competent CDI (in regards to MDs) is to educate them on communication skills. We are having a teambuilding retreat on Friday that will incorporate Myers- Briggs Type Indicator to help us gain understanding of our own communication style. We will then have quarterly classes with the OD dept. of HR to help enhance and grow our communication skills. I believe building rapport and relationships with physicians is a major factor in CDI success! We can have all the knowledge in the world, but if we cannot speak with MDs and help them understand, what difference does it make?
5. Not sure what "evidence based" criteria is for a query. Do you mean definitions that are current and well-researched?-Yes.
6. Our "theory" is persistence, attitude, and communication. I sometimes feel like the man from that 70's show "Fantasy Island" (dating myself). He used to start every show with "smiles everyone....." As the manager, I send the CDI team out to their day ready to perform. And, how well we perform will be reflected in our response rates and our physician buy-in. Sorry if that sounds corny but you do get further with honey than vinegar:).
-Jane
We split the daily admissions 3 ways. It makes for more even workflow for everyone. Admissions are priority, then queries and followup.
We focus on DRG payors- M'Care, Blue Cross,Tricare. We would love to incorporate all payors but it would be impossible. We review 68% of our M'Care adms.
Currently our program is a Hybrid model. Our job description is open to RHIA, RHIT, CCS, RN, & LPN. At some point in time we have employed all credentials except an RHIT. Two of us are CCDS, & 1 is CDIP. Another to sit for her CCDS this next year.
At this time we have 3 CDS- RHIA & 2 LPNs. We would like for our applicants to have some coding background but its very hard to find hires w/coding experience. (Its hard to find people who even know what CDI entails.) Mostly we have had to train from scratch. Would love to send hires to Boot Camps! We've actually suggested that to upper management.
We were originally staffed for 5 CDS per the consulting group which provided our training. We are hoping to be given another position. Hopefully we will hire an HIM applicant to keep a balanced group.
We do have a very diverse physician culture but we've not had any particular training for that one dynamic.
If by evidence-based you mean offering Clinical Indicators within your queries, then yes. Our queries have areas for clinical proof incorporated within them. They are Word document Templates so we can customize them for our patients.
Norma T. Brunson, RHIA,CDIP,CCDS
** We staff by units and but divide the list if one is a bit over scheduled for the day to even out the load. Everyone works together to get it done. We review everyone but OBS status and OB/Newborn.
2. How do you recruit, select, and coach staff? What is your retainment and turnover like?
** We recruit nurses from within our facility if possible in the area that we need the coverage so they already have training on that particular floor as a nurse and are known by the MD's. In our area, there arent CDS readily available. We train from within and use as many outside sources/training material that we can get our hands on. We have three CCDS, one that is eligible to sit and another that will be ready next year.
3. Do you have any efforts to increase the number of BSN nurses?
** BSN/Associate Degree, one not chosen over another. You can't beat ANY nurse with several years experience in the trenches, no matter their educational background. We are currently all Associate Degree RN's with three working toward their BSN.
4. Given that physicians are often times a diverse culture and one of our larger stakeholders for CDI, do you have a role in developing culturally competent CDI? ** We are not really culturally diverse where we are....
5. Do you use evidence based criterias for your query process?
** Tried and true guidelines are what we follow.
6. Lastly, do you incorporate a specific theory for your practice? ** The theory is to have the highest degree of specificity regardless of revenue, quality, etc. If you do this, the rest will follow. We are all OCD and do what has to be done to complete the job. I work with a great team!!!
April Floyd, RN, CCDS
Director of CDCI
Anderson RMC
We try to mix in all payers into our review – Medicare, Private, and Charity.
We review for DRG and ROM – we also ‘help’ the Core Measure, VBP and PSI angle in that we will query for pertinent issues as will communicate with the Core Measure Abstract Team if we query for PNA, CHF or MI .
Our model is hybrid and we open the position to RN or RHIA while stating CCDS ‘preferred’ - our team is 100% CCDS credentialed. I will now probably accept the new AHIMA credential as well, but it did not exist when we built this program. Our training philosophy is to find applicant and train internally, but have them attend a Boot Camp program.
We use evidence-based criteria in our queries and endorse this concept rigorously.
I have extracted portions of our query philosophy or theory?
Clinical Documentation Integrity (CDI)
• Accuracy and precision in provider documentation is the goal of the CDI professional. Accurate documentation, and the precise medical coding it allows, has significant positive impacts on multiple healthcare parameters. Quality metrics, appropriate reimbursement, communication within the care team, regulatory compliance and patient safety all depend upon clarity in the medical record. Only when diagnoses and procedures are consistently and clearly supported can they accurately be captured by coding staff. Put simply, clear, complete documentation is one of the foundations used to measure and grade modern medical care. . The role of the CDI professional is to obtain clarity in the medical record. This includes, when appropriate, CDI initiation of the provider query.
• Queries are used to clarify potentially ambiguous provider documentation. When used effectively a CDI program’s use of individual query forms enhance Medical Staff appreciation for thorough documentation and coding. When used improperly, however, the query process can seem needlessly intrusive and disruptive to providers. The CDI professional when querying must keep in mind respect for the physician while also furthering program goals. It is essential before making a verbal or written query that CDI staff ensures relevant clinical criteria are met. The West Bay Region CDI team has published many evidence-based definitions of common query topics and terms. The CDI specialist must be familiar with these definitions. A query will be initiated only when clinically appropriate. For example, not all pneumonia cases require a query for possible complex disease. If the medical record states a pneumonia patient is being treated with Rocephin and the length of stay is short it may not be appropriate to query for a ‘complex’ type of pneumonia. Conversely if a patient has a length of stay longer than is typical of a ‘simple’ pneumonia and/or the patient is being treated with Gentamicin for Gram-negative rods, a query may be considered.
• Only query forms approved for use by the West Bay Region will be used.
• It is appropriate to generate a physician query when documentation in the patient’s record fails to meet one of the following five criteria:
1. Legibility
2. Completeness
3. Clarity
4. Consistency
5. Precision
• A query may be generated by a CDI or Coding specialist for needed clarification in regards to:
1. Primary diagnosis
2. Complications
3. Procedures performed
4. Clinical significance of abnormal findings (laboratory, X-ray, pathologic, and other diagnostic results) when not documented.
5. Presence of an uncertain diagnosis that was documented in the medical record but not at the time of discharge
6. Clinical indicators of a diagnosis without documentation of the condition being present
7. Clinical evidence for a higher degree of specificity or severity than documented
8. Establishing a cause-and-effect relationship between conditions and organisms
9. Establishing an underlying cause of documented symptoms
10. An indication for a treatment that has not been documented
11. Conflicting diagnostic statements among different providers
12. Inconsistent language in describing a clinical condition or procedure
13. Uncertain present on admission (POA) indicator status
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
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Don