One of our Biggest CDI Challenge winning stories by Stacey Forgensi was chosen not only for the title [Accountability: The Missing Link], but also because Stacey presents over 10 different strategies for obtaining accountability for physicians based on her own experience. In the end, she shares with us both the positive and challenging sides of her work: surgeons did not cooperate, but it looks like the Family Medicine physicians are on board. So, it appears that Stacey's multi-tiered strategy to CDI is beginning to pay off after all. Read about Stacey's challenges, successes, and all of the strategies she employed (strategies are in italics) to increase the accountability of the physicians on her medical staff.
The biggest challenge faced as a Clinical Documentation Specialist (CDS) is physician accountability to comply with our Clinical Documentation Improvement (CDI) program. I work at a level one trauma center affiliated with a university residency program. To make matters worse, we do not have buy-in from the attending physicians, who do not care if their documentation is lacking and are not afraid to tell me so. Likewise, they do not care about financial gain to the hospital when I further explain that if the hospital does not make money, they close their doors, and they will be unemployed. Additionally, I explain that if the hospital is accurately reimbursed for services provided, they ultimately benefit. For example, new operating equipment will be purchased, faster scanners, etc. This provides no motivation, as they tell me they can go to another hospital, not realizing that CDI programs exist everywhere. Without strong leadership, doctors are non-compliant, and CDI programs will fail.
Our physicians have a 75% query response rate, and monthly reports reveal each physician’s statistics. Results are tied into their contracts. Pay cannot be withheld, as most are paid by the university, not the hospital. Next, I explained physician report cards and how savvy consumers can compare physician profiles online. Most were unaware of this, but again, it did not facilitate change. I decided change was needed, one department at a time. First, I chose the service with the worst documentation but the most potential: the Department of Surgery.
I recently conducted a research study to see if it was possible for surgeons to improve their documentation. I tracked and trended queries, response, agree, and no response rates. Weekly presentations were conducted after teaching rounds, and new residents were mandated to attend by the vice president of trauma and surgical services and the chief of surgery. A scenario was given at the end of the presentation, and residents were asked to write an admit note based on the scenario. Many tools were instituted to help with documentation. Tabbed dividers with documentation tips were placed in the front of every inpatient chart. Excisional debridement posters were hung throughout the hospital in pertinent places, such as surgery on-call rooms, conference rooms, operating rooms, and dictation areas. A debridement procedure note was created as an electronic form requesting all the pertinent information a coder would need. Bookmarks were distributed with the top ten queried diagnoses, and on the back were tips on what to include in history and physicals, daily progress notes, and discharge summaries. Pre-printed daily progress notes were created that included common surgical diagnoses using a checkbox format. Physician newsletters were published monthly with documentation guidelines, coding rules, and a “diagnosis of the month” commonly documented incorrectly.
After six months of education and implementation of the tools, the research showed that documentation did not improve. Results demonstrated that presentations were effective, as the documentation improved when tested at the end of the session. However, when it came to documenting on real patients, they did not improve. Survey results rated knowledge of documentation in relation to coding before and after educational sessions using a 1-5 Likert scale. Results of the survey indicated a vast increase in knowledge of documentation and its importance. Unfortunately, progress notes contained less information than previously. Debridement forms were not used, so when evidence of a debridement appeared in the medical record, a form was placed in the chart to complete. Again, the forms were not completed.
In conclusion, the Department of Surgery did not improve their documentation. They demonstrated they understood the importance that the medical record needed to tell a story; however, they chose to be lame and document poorly. Alternatively, a refreshing request came from Family Medicine who wanted to increase their case mix index. Working with their case manager, residents, and attending physicians, they hope to capture accurate severity of illness on their patients. They are willing to do anything necessary to improve. The institution of problem lists track diagnoses as they occur, and residents will use the list when dictating their discharge summary so that they do not omit important diagnoses. Weekly presentations with case studies will keep them abreast of progress. It’s exciting to have a service interested in improving their documentation. Maybe the idea will be infectious.
