Coder-RN CDS team question

catladyrn

Hi all,

For those of you who work in a collaborative environment where both the coder and the RN are reviewing the chart concurrently, what process do you use to track query productivity? I am concerned that when each member of the team is measured on how many queries they've sent, and you have two people reviewing the same chart, there might be competition to try to be the first to get the query out. Any thoughts on how to measure productivity fairly without bringing out gamesmanship? Thanks.

Renee

Linda Renee Brown, RN, CCRN, CCDS

donna.kent

I'm sorry that our field is still plagued by "number of charts reviewed
and number of queries placed". In my opinion what we are going for is
accuracy in the entire medical record. Queries certainly help with that
process. However, if we see ourselves competing or feeling like we have
to compete for "numbers", I fear we are not as likely to be achieving
the goal of accuracy as it demonstrates the quality of patient care
given.

Sorry for the soap box but being forced in to "bean counting" is not
what ultimately enhances better quality for our patients.

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

dbutler

Related, one of the issues that I am now having to figure out:
Have a couple of the much more experienced CDS's on our team that have also been working with the same group of physicians. Their query rates are dropping -- not because they are missing anything, but because they HAVE been successful influencing physician documentation among their core group.

Since metrics do influence annual evaluations, I need to figure out away for those folks to be fair. Most likely is to 'balance' the lowering query rate with audit results (where I can show low rates of 'missed' query opportunities with the same CDS's). Need to have an objective, simple way to describe this!

In general, bringing more weight to audit results promotes the idea of quality, accurate medical record -- were things missed that needed clarification? (not how many questions were asked).

On Renee's original question -- why is the structure where both a coder & an RN are reviewing the same chart? I presume both are reviewing concurrently? I suspect a large part of the answer on how to be fair comes back to why they are paired.

I do see the quandary. Perhaps the answer would be to look at the total query rate on the basis of the team/pair -- not individually?

(Hi Renee!)

Don

Unknown

Donna,

I wholeheartedly agree!

vdavis2

So agree with Donna on this one! Our teams do a lot more than just query.. we do everything! So for those that just like #'s-Measure EVERYTHING!!! That will keep you tied up for a while!

To answer Don's question: Since we are a community hospital we were able to simplify this by not having assigned units... we keep our skills up in all areas and network with all MD groups. We also have the luxury of location- our offices are right beside the MD lounge, the hospitalist's main office/workroom, and our clinic offices are right around the corner!

Vicki S. Davis, RN, CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Hospital
336-586-3765 Office
336-586-4191 Cell
336-538-7428 fax
vdavis2@armc.com

"The biggest problem in the world could have been solved when it was small.." Witter Bynner

evanspx@sutterhealth.org

Regarding drop in query rate and drop in financial findings directly
associated with such a drop, you may want to include some type of other
metric that is positively influenced by CDI activities.

As one example, our facility attained and sustained marked advances in
our O/E metric (I should not cite exact numbers on this venue), and the
executives agree this happened due to CDI educational efforts,
presentations, and concurrent chart reviews.

So, while the directly measured $$ of outcomes will decline as a CDI
program matures, (as it should), one may still devise a metric stating
something like:

"The facility O/E rate shall be at or below 1.0 for the fiscal year"

Or,
"The CMI will be at the XX% of the national average for our peer group
based on MIDAS/Med Par data" - in this fashion, the CDI team can get
some credit for holding the base line CMI to a goal, while acknowledging
the multiple factors beyond CDI that affect the CMI.

Just a thought

Paul Evans, RHIA, CCS, CCS-P

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

lsipos@monument.health

Quality....QUALITY.... thank goodness our program (though measures this), does not use it as a deficit for evaluation. It is a matter of quality for the patient to measure only-SOI, ROM, LOS and areas for documentation improvement!

Juli Bovard RN CDS
Rapid City Regional Hospital

Unknown

Hi: I look at CMI, %cc, %mcc and % of accuracy between the CDS team and the coder. The CDS team does not have a completed record as the coders who have a completed record. I don't expect 100% accuracy since doctors always seem to add something to the discharge summary that we didn't see in the record. I also review all coded inpatient records to make sure CDS and the coder did not miss an opportunity to capture the appropriate DRG. We also are responsible for make sure the core/global/scip measures are addressed and met. I can't see evaluating based on queries. There is so much more involved and as someone said, your doctors may be better at documentation than someones elses doctors. Just my thoughts. Georgia Chounard, RN, BSN

sbeatty

We have a program review rate that was initially set at 30-40% overall query rate when we started 10 years ago. Since we implemented a hospitalist program, those MDs are much more invested in our work than some of the other physicians ever were, and we see our rate slowly trending down (currently around 20-25%). However, our CMI is stable over time, and our capture rates are still stable, so we aren't measured for performance on any of these metrics individually. We monitor them for program wide performance. I've been working on a measurement strategy that would be more meaningful to us as CDS, and also determine where our biggest opportunities are now that we are 3 years into a hospitalist program, and with ICD-10 coming. I think that is were the emphasis needs to be. I'm very thankful that our organization has always been about quality first and foremost. If you get the best, most accurate documentation you can, the money will take care of itself. Leadership knows this, so I feel for those who have their proverbial feet held to the fire for more money. I find it quite a scary proposition.

robert.hodges2

I've seen the same trend in my queries over time in the acute care setting. I do track what query types are sent and response rates. I also capture if a more precise code is applied as a result of a query or if a previously not documented diagnosis is identified, for example nursing documents right sided weakness do to an old stroke and I query asking if that finding by nursing is clinically significant and the provider documents the late effect of the stroke.

I'm not sure if this is what you are looking for, but hope it helps.

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

don.cdi.rn@gmail.com

Paul -- great thoughts.
We are part of University Healthcare Consortium, and I do look at mortality O/E from their database (and have that as one of my goals this year).
I also like the goals you've outlined regarding CMI, phrasing the way you've suggested had not occurred to me.

Unfortunately I can not drill down to look at the individual CDS areas to correlate to individual performance, which is why I was looking at audit data which can be drilled down to the individual staff level.

Thanks! Don