CDI audits

Hello.  Our CDI department is looking for someone to audit our charts.  Especially looking at our queries and DRG's.  We are wanting to find our baseline.  How do other CDI departments determine there baseline?


  • edited August 2018

    Setting a baseline is simply enough.  
    Audit 100 records and determine an accuracy level on a few axis:
    Completeness and appropriateness of the clinical indicators used in the query.
    Compliance with the AHIMA practice brief on query writing
    Review Rate
    Query Rate
    Response Rate
    Agree Rate

    What ever findings you come up with is essentially your baseline.  When I was a manger I gave my staff a goal of improving by 5% per quarterly if they did poorly, 3% quarterly if they were average, 1% quarterly if they performed well.  Achievement is rewarded with an extra day off or reflects in their scoring on their annual evaluation or a few dress down days or long lunches etc.   Rarely did I consider any sort of punitive measures but preferred increasingly desirable rewards for good performances.  (Maybe the highest performer gets a title of "lead CDI" and the "most improved" in a year gets to go to the conference).  :)

    I discourage the use of a "one size fits all" baseline however and encourage you to give each CDI their own individualized baseline and custom performance improvement goals.   Other wise, you will only favor the top performer and punish the rest of the staff by potentially holding them to an unrealistic performance metric. 

    Notice I did not include "coding accuracy" or "match rate with coding" as a metric.  Having said that I would measure and baseline it for tracking purposes and I would use it for education (it is one of your best tools to identify areas where education is needed) but I would not use it as part of the performance evaluations. 
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