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Copy of Clinical Documentation Improvement Program

A look at industry Best Practices for Virginia Mason
by

Cassandra Merry

on 31 May 2011

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Transcript of Copy of Clinical Documentation Improvement Program

Clinical Documentation Improvement Program Jennifer Abenojar and Cassandra Merry A Look At Industry Best Practices and AHIMA Standards What is Clinical Documentation Improvement? Capstone Project Description Analyze the current Clinical Documentation Improvement program (CDI) in place at Virginia Mason and to make suggestions for improvement based on other facilities in the industry and AHIMA standards for CDI implementation and maintenance. 2010 AHIMA Publication entitled Clinical Documentation Improvement Toolkit This Means That... The purpose of a CDI program is to initiate concurrent and, as appropriate, retrospective reviews of inpatient health records for conflicting, incomplete, or nonspecific provider documentation. These reviews usually occur on the patient care units or can be conducted remotely (via the EHR). There is designated staff that is consistently looking through physician clinical documentation while the patient is being seen to ensure that all possible diagnosis are being recorded.
The goal of any CDI system is to improve the information that is being recorded within the patient chart to ensue that it reflects the patients actual conditions as best as possible.
The overall goal is to improve the quality of care that we are able to provide and to ensure that we have all of the information gathered and reported. History of the Virginia Mason CDI Program In 2007 VM implemented a 'Home Grown' CDI system. This system was developed by the HIM team and had an associated physican education program

Two years ago VM implemented a CDI system with the assistance of Bearing Point, an outside consulting firm.

With the new Bering Point CDI system the original physician education program has been eliminated from the program.

As a result of this implementation over the past two years VM has steadily increased their Case Mix Index as well as their quarterly CMS reimbursement rate Steve Schafer
Virginia Mason Vice President Beckey Foley, RHIA
Virginia Mason HIHIM Director Jean Krehbiel, RHIA
Manager and Clinical Coding Director Physician Advocate - Medicine
OPEN Physician Advocate - Surgery
Leave of Absence Coder Coder Coder Coder Coder Coder Coder Coder Registered
Nurse Registered
Nurse Registered
Nurse Registered
Nurse According to AHIMA, a successful
CDI Program Needs: 1. Physician Advisor / Champion

2. Hardware and Software Requirements

3. CDI Review Forms and Tools

4. Policy and Procedures that address
physician education and compliances Recently Virginia Masons advancements in CDI have reached a plateau

Lack of increase in Case Mix

CDI Nurses are finding that they are sending the same queries to the same physicians

Physician's who responded to queries still are responding, however no new physicians are participating in the CDI program Current Problems: How Does The CDI System Work At VM? Physician sees patient and makes a record of care that was given If the patient is over the age of 60, or a CCU7 case, the chart is reviewed by a CDI nurse from a remote location If the CDI Nurse sees room for additional information or missing diagnosis, a query is developed and sent to the Physicians Cerner inbox. If the physician sees the query and agrees, an amendment is added by the physician to the patients progress notes If the physician disagrees with the query there is no amendment made to the patient chart. If the physician never sees the query or simply does not respond, the query is resent to the physician from the Coding team at the time of discharge EDUCATION PHYSICIAN CHAMPION WRITTEN POLICY AND PROCEDURES These policies should be developed by the Health Information Management department and made available to all participants in the program to ensure compliance and a universal understanding of expectations. Suggestions For Improvements What Is The Problem? These suggestions
Development of an education program
Maintaining a physician champion
Development of written policies and procedure
are components that are currently working in other facilities in the area, including The University of Washington Medical Center, Group Health as well as being suggestions for success from AHIMA. Conclusion: Goals of a Clinical Documentation Improvement Program: Improve individual physician ranking in the medical community

Increase facility Case Mix

Improve the accuracy of patient charts and recording processes

Increase CMS reimbursement rate

Educate physicians on how to chart as accurately as possible QUESTIONS? The Clinical Documentation Team at Virginia Mason Wait...What...? About Virgina Mason Justification For Suggestions An education program needs to be developed, maintained and promoted by not only the HIM department but also physician champions. This education program needs to be extended to all departments of medical staff as well as incoming residents. This education program will enhance early physician buy-in and express the importance and implications of ideal charting. A physician champion is needed to implement and maintain a successful CDI program, serving as a liaison between CDI staff and the medical staff. They help to encourage physician cooperation with the program and act as an advocate for the CDI program. Any program within the hospital will eventually fail without the buy-in from the medical staff. Two: Three: One: What Does CDI Workflow Look Like?
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