The writer addressed her organization's CDI program accomplishments: "Our CDI Program has been in place since 2005. When we began the program we brought in outside consultants, including physicians, to train the medical staff, HIM nurses, Coders, and hospital administration on the fundamentals of the program and on the principals of documentation. Although we have had notable success with the physicians improving their documentation, we have not been able to find a way to sustain this success. The doctors understand what they are supposed to do, but the minute we 'look the other way' they go back to their old ways of marginal documentation. We try to keep their interest with incentives through monthly and quarterly awards (recognition for good examples of documentation or most improved) as well as on-going education and feedback. Therefore, we would have to say that our "Biggest CDI Challenge" is to find a way to permanently modify physician behavior."
The two key issues addresed in this submission around permanently modifying physician behavior are: (1) sustainability and (2) physicians going back to their old ways of documenting when the CDI staff "looks the other way". To address the issue of permanently modifying physician behavior both of these issues must be addressed. First, let's discuss the concept of sustainability. Lack of sustainability was one of the biggest complaints I heard as a consultant when talking to decisionmakers at hospitals who were potentially interested in implementing a CDI program. Many organizations had implemented CDI in the past, but found the program unsustainable - or, they had heard the lack of sustainability argument from other hospitals. Any organization looking to invest time and money in a project is also looking to ensure some degree of longevity. How, they would ask, can you guarantee sustainability?
The answer to this question was never an easy one. The answer starts out with "it depends".....And, as it turns out, sustainability depends on many things. First, and, of course I probably sound like a broken record by now, but sustainability depends on the quality and quantity of CDI education that you provide to your physicians. In fact, it was this exact question about sustainability that got me started on my 7-year research project around physician education, CDI and sustainability. And, from that project grew the CAMP Method for training physicians and clinicians in CDI - proven through an interventional research study to improve both quality and sustainability of physician clinical documentation practices. While I would like to believe that this training methodology will ensure sustainability in perpetuity, this is probably not the fact. It is possible however, that continued re-training using the method is likely to result in sustainability - but this has not been proven through research - yet. Re-training using the CAMP Method is a good (and necessary) first step.
Second, sustainability depends on the culture and support of the organization. What works for one organization may not work for another. So, you must understand your organizational culture as well as the culture of your physicians - and use that knowledge to make decisions about how to create the details of your program. For example, how you share CDI results reporting and what the reports look like may make a difference to your physicians. The same goes for how queries are asked, how physicians respond to queries, and even who performs follow up training. Whether directly or indirectly your physicians need to have a hand in all of this decisionmaking.
We know from research in behavioral psychology that individuals are more likely to buy into a process if they have been part of creating it. What better way to modify physician behavior than pulling them into the decisionmaking process? Of course, this can not be done overnight . But, if you can work with physicians to be invovled in even the smallest of decisions, it will improve buy in. One example of physician participation in the decisionmaking process for CDI with a hospital system I worked with in the past invovled the response rate. In this hospital, each department chair was asked to consult with his or her physician members and determine what they were willing to commit to as an overall response rate for queries for their department. The rates varied by department - from a low of 60 to a high of 95 and in all but one case, after the first and second quarters, all of the response rates were met.
Third, as far as physicians "going back to their old ways", while their involvement in the decision making process will help, this is a issue that requires ongoing vigilence from the hospital CDI staff. The vigilence is not just looking over the physicians' shoulders, but more importantly, continuing to identify opportunities where physicians can be involved in the decisionmaking process and, essentially in shaping the future of what their clinical documentation practice looks like. The EMR is a great example of involving physicians in a current change process invovling technology that simultaneously involves clinical documentation. The list may look slightly different for each hospital, but the activity remains the same.
The CDI staff will, to some extent, always be responsible for managing physician behavior. This is likley to last until CDI become embedded in medical school curricula and residency training programs. This last statement is really the key to modifying physician behavior....having CDI training embraced by all of their peer organizations: medical school CME programs, professional association CME programs. Once physicians are exposed to the topic of high quality clinical documentation practices everywhere they turn - not just the hospital where they admit patients - they will be more likely to comply consistently. That may be as close to permanent modification as we can ever hope for.
