Question about internal quality review process
Does anyone out there do concurrent and/or retrospective audits of CDI
cases for quality? If so, who performs the audits? Also,do you have a
minimum quality expectation?
We don't have a formal process yet, but we are thinking it would be a
good idea to begin implementing one.
Karen A. Johnson, RHIT, CCS
Supervisor, DRG Assurance
Cleveland Clinic 216-444-3559
cases for quality? If so, who performs the audits? Also,do you have a
minimum quality expectation?
We don't have a formal process yet, but we are thinking it would be a
good idea to begin implementing one.
Karen A. Johnson, RHIT, CCS
Supervisor, DRG Assurance
Cleveland Clinic 216-444-3559
Comments
MEI LI. RN, MHA, CDIS
WEST HOUSTON MEDICAL CENTER
CLINICAL DOCUMENTATION IMPROVEMENT SPECIALIST
HIM DEPARTMENT
12141 RICHIMOND AVE
HOUSTON MEDICAL CENTER
OFFICE: 281-588-8560
CELL: 832-878-2518
Email: Dong.Li@hcahealthcare.com
"Knowledge has to be improved, challenged, and increased constantly, or it vanishes.
-----Peter F. Drucker
I also have CDIS and 3 M are our consultants, the benchmarks below are for program expectations and I do not think for process compliance.
If anyone out there has an audit process in place I would also like to hear how it is going and tools if any if you are willing to share.
Thanks
Lois Rubin RN, BSN, CPUR, CCDS, CCS
Supervisor, Clinical Documentation
Case Management Department
St. Peters Hospital
Does your CDI program have written policies and procedures in place?
http://www.hcpro.com/acdis/view_readerpoll_results.cfm?quiz_id=2061
What is your process/policy for ensuring that physician queries are compliant (i.e., non-leading)?
http://www.hcpro.com/acdis/view_readerpoll_results.cfm?quiz_id=2019
Do you audit your CDI specialists queries?
http://www.hcpro.com/acdis/view_readerpoll_results.cfm?quiz_id=1903
Who do you use to perform quality audits on your CDI staff?
http://www.hcpro.com/acdis/view_readerpoll_results.cfm?quiz_id=1673
There are many other VERY good poll questions that you might find useful, especially a number on policies and procedures as well as on queries. The archives of the polls are located:
http://www.hcpro.com/acdis/readerpoll_archives.cfm
Also would suggest looking at:
On the helpful resources page (under White Papers):
Benchmarking Report: Survey offers physician query best practices
Look through the ACDIS Article of the Month Archives
On the Quarterly Journal page: http://www.hcpro.com/acdis/archive.cfm?topic=WS_ACD_JNL
July 2010 -- Survey shows structure of healthcare documentation improvement programs
Plus several articles that might be of interest -- browse through.
I had started to develop an audit program, but we've been short staffed for quite some time and have not been able to implement as of yet. Focus on both cases with queries as well as some cases without queries. Issues such as adequate review, missed opportunities, appropriate working DRG at last review, ....for queries: compliance, appropriate timing, language, clinical support, good balance (not overly aggressive or too delayed), good follow through and resolution, well worded, appropriate options, formatting of the question itself (bullets, run-on...), etc.
Intend to do the audits myself, a relatively small number (no more than 10 cases/month/CDS -- which would be 90).
I also use data analysis as a tool for audit of performance -- can reveal quite a bit about individual performance both among CDS staff as well as over time for the individual.
Don
Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com
Never give in. Never, never, never, never--in nothing, great or small, large or petty--never give in, except to convictions of honor and good sense. Never yield to force. Never yield to the apparently overwhelming might of the enemy
Sir Winston Churchhill