1. Your observed to expected mortality rate is way off. Many hospitals and health systems are struggling to improve comparative mortality data. I've experienced the anxiety, as a physician executive, of having below average metrics in multiple clinical departments despite the fact that I observed the delivery of very high-quality care. Even though we implemented numerous quality improvement initiatives, we were never able to drop our mortality rates in these departments or service lines below the mean. However, within a short time after we implemented our clinical documentation program, all of our service lines vaulted to a level significantly better than the national average for mortality, and many were in the top quartile. Don't underestimate the importance of documentation accuracy to capture severity of illness — a key element of any severity adjusted outcome metric. If you've experienced high mortality or morbidity rates due to poor documentation under ICD-9, the increased requirements for specificity under ICD-10 will likely make your situation worse.
2. You aren't actively monitoring your CDI program and benchmarking yourself to your peers. There's an adage in performance improvement that "you can't improve what you don't measure." Do members of your leadership team, including physician executives and those operationally accountable for documentation and coding know where you compare against peer group hospitals (hospitals with similar services and complexity)? MedPAR data is a useful starting point, but it is also essential to compare your performance with like hospitals, not only at an aggregate level, but also by clinical service line. Significant documentation issues can be identified through analysis of service line response rates, CC and MCC capture and other metrics. Physicians are inherently competitive and are motivated to improve performance when the measured quality of their clinical outcomes is shown to be negatively impacted by poor documentation. Monitoring data alone is insufficient. If that data is not shared openly with physicians, it can have little positive impact. Let's expand the adage: "You can't improve what you don't measure and share with those who have the capacity to improve the measured process."
3. Your medical staff feels that clinical documentation improvement is an HIM, coding, or revenue cycle program. Who owns your clinical documentation program? It is key for program success that physicians identify clinical documentation improvement primarily as a quality issue: quality of care and quality of data. If your physicians feel that your CDI program is only about making more money for the hospital by DRG "maximization" or "optimization," your physicians have every reason not to prioritize its importance. Accurate clinical documentation provides the basis for high-quality care and should be managed as a clinical process running concurrently with patient care. Successful hospitals typically have physician leaders supporting a collaborative effort with HIM and coding. It is very important that medical leadership understand the logic, the process and the metrics. Advanced programs routinely share performance information with medical executive leadership, departmental leadership and individual staff physicians. It is less important who has day-to-day management authority for the CDI staff than it is for the medical staff to be able to observe their leadership colleagues actively sponsoring and guiding the program.
4. You don't have dedicated clinical documentation specialists on staff. At many hospitals, clinical documentation has been combined with coding or case management functions, confusing physicians as to the role of clinical documentation improvement. CDI programs should stand "on their own" in order to gain the necessary physician endorsement to support accurate and complete provider documentation. The need for advanced practice CDI will escalate as hospitals prepare for the conversion to ICD-10. Accurate, detailed clinical documentation will be more important than ever to attain various benefits of the increased specificity offered by the numerous ICD-10 diagnoses and procedure codes. A clinical documentation program, supported by dedicated clinical documentation specialists, provides physicians a more complete view of relevant findings within the medical record, supporting compliant documentation while it still matters —when the physician is still treating the patient.
5. You are relying on computer-assisted coding to solve your ICD-10 documentation problems. No matter how sophisticated the computer-assisted coding tool, one can't avoid the fundamental fact that a CAC program will only assign codes based on documentation in the record. The risk of applying CAC technology, in the absence of sophisticated clinical documentation improvement infrastructure, is profound. While such technology is designed to assist coders through the complex world of ICD-10, if physicians do not provide appropriate documentation, the amount of coder rework is likely to increase dramatically. Coding rework results in increases in the number physician queries, negatively impacting physician workflow and satisfaction. Physicians need ICD-10 education, specific to their specialty or subspecialty and an advanced collaborative CDI infrastructure, so that the medical record content captured by CAC technology will provide valid ICD-10 coding information for your coding department.
Dr. Paul L. Weygandt has been the vice president of physician services at J. A. Thomas & Associates — now part of Nuance — for more than eight years. In this capacity, he has coordinated and delivered physician education seminars, in-services and individual physician support in numerous client hospitals across the country.