With big health systems come big responsibilities

Of the 4,840 short-term acute care hospitals in the United States, 3,231 of them were part of a hospital system in 2016, according to the American Hospital Association. Though the 2017 data has yet to be released, one might naturally assume the number would increase, as every day seems to bring new stories of hospital mergers and system acquisitions.

For CDI programs, this prevalence of health systems over freestanding facilities can pose a major problem for uniformity of education and CDI practice. CDI program managers and directors in multifacility systems often struggle to overcome individual hospital culture, create collaborative climates, craft effective (and standardized) query practice policies and procedures, and establish productivity expectations.

When the CDI team is distributed between several facilities of differing types and patient populations in several geographic locations, CDI managers and directors have the difficult role of bringing them together to form a cohesive and successful team.

Since CDI leaders can’t be in five facilities at once, how do they approach managing their team effectively?

Assess the culture
When a new manager or director steps into the role, the job of unifying a distributed team can seem daunting. Even the most stalwart of leaders may not quite know where to start. The best way to begin is by assessing the current cultural landscape across the system—in other words, establishing a baseline, says Tonya Motsinger, MBA, BSN, RN, system director of CDI at Ohio Health in Columbus.

“When I first started, we had five campuses and then one independent campus. They range from a small community hospital to our largest, which has more than 700 beds. They had a nominal cross-campus collaborative effort at the time,” she says. Her 12 staff collaborated about once per month, but their independent processes and cultures were very different.

No matter where the culture stands when you begin, efforts should aim at transparency across the system. This will ensure every facility’s team knows what the other facilities are doing, says Mel Tully, MSN, CCDS, vice president of CDI clinical services and education at Nuance, based in Atlanta.

“You have to try to keep consistency of a CDI program to be able to provide the support that each hospital deserves,” she says.

Building that transparency also helps to increase the feeling that, although they’re spread across several facilities, the CDI team is united and can rely on each other when questions arise.

Standardize processes
CDI managers and directors need to find ways to build the trust between the dispersed team members. Motsinger says this can only be fully accomplished by maintaining the personality (so to speak) of each facility while streamlining the processes of all the individual CDI teams.

“We immediately started working on putting processes in place across the system. It had to work across all the hospitals,” she says. “We wanted to be careful to preserve some of the personality and cultures of the various hospitals, but at the same time, we needed the processes to look the same and the experience for the physicians to be the same.”

Having consistent processes presents a unified front to the system’s physicians, and it allows individual CDI specialists to help each other out, even across facilities, Motsinger says. This could be especially beneficial in instances where a facility within a larger system only has a single CDI professional on staff. When that lone CDI specialist encounters a question, he or she needs to be able to reach out to another facility for answers. This can only happens when the processes are uniform—and only if the team member knows those distant colleagues well enough to reach out.

“If another campus has a question on something, they need to feel safe calling another facility,” says Motsinger. “That was a really big and important goal for our team to meet: to create a very safe environment.”

Systemwide policies and procedures also help ensure cross-coverage for vacations and sick days. According to Tully, CDI program managers and directors need to ask themselves, “Do you have the ability to allocate or assign floaters, or interims, or people who do remote reviews to fill the gaps across the whole system?”

For example, if that lone CDI specialist goes on vacation or gets sick, what happens to the reviews in the interim? If there’s no one to pitch in, there’ll be a mountain of reviews once the specialist returns; patients may be discharged and bills dropped before he or she can get to them. If the CDI processes and policies are uniform across the system, however, a CDI specialist from another facility could easily jump in and, following the same process as always, successfully conduct chart reviews and issue queries in place of the absent staffer.

“We tried to preserve the individuality of each facility, but also make sure things are systemwide so there’s coverage,” says Motsinger. “If someone is off, someone else can effectively jump right into that person’s patient population.”

Share information
For those systemwide policies and procedures to be universally implemented, there needs to be some sort of system for sharing information. CDI managers and directors have to ensure that the information disseminated to the various facilities comes from one location, avoiding a telephone-game situation where the end information is a garbled version of the original.

While there are a number of ways to accomplish this, Tully suggests facilities institute a steering committee to develop and disseminate the policies and procedures. That steering committee should include all the key players from the hospitals so that the agreed-upon policies reflect stakeholder goals, she says.

Then, once the policies have been settled, the steering committee should be the governing body to pass along the information to the individual facility leadership, making sure nothing gets lost in translation along the way.

“Information sharing should really begin with the steering committee,” says Tully. “Everyone should do everything pretty much the same, and if there’s a caveat, everyone should recognize that caveat.”

Motsinger also suggests holding regular meetings with the CDI staff from all the facilities in attendance. Not only does this aid the dissemination of uniform information to all the facilities, but it also serves to build a team atmosphere by creating face-to-face learning opportunities and comradery across the program.

“We have a monthly system meeting where everyone comes. If they’re at a farther campus, they can video in, but the important thing is that we can see them and they can see us,” Motsinger says.

Between those in-person meetings, all the information—whether it be an escalation policy, query templates, or educational tools—should be stored in a place that’s easily accessible for all the facilities. That way, even between meetings, everyone has resources at their fingertips. At Ohio Health, Motsinger stores all those documents online for easy access.

“We have a well-developed e-source site for information sharing created by one of our CDI committees,” Motsinger says. “People’s calendars are in there so everyone knows when people are off too. There’s one place everyone can look for everything.”

Get creative
Sometimes a CDI manager or director needs to take a creative approach. Though group meetings and systemized processes will certainly help create a uniform CDI program across the system, it may not have as much success in fostering a true team spirit than other, more creative approaches since everyone still works daily with only their facility team.

“We created cross-campus committees that help people get to know each other and collaboratively work on projects that impact our outcomes for the entire system,” says Motsinger. These committees helped the team recognize that, although they’re responsible for their individual facilities, together the CDI team is working for the good of the whole system, she says.

Those smaller committees could also be segregated to each facility with the enterprise committee comprised of representatives from all the facilities, Tully says. “It’s important to have an enterprise steering committee,” she explains, “but also to have individual committees at each hospital reporting up to the enterprise committee,” to ensure that each individual facility’s voice is heard by the larger whole.

Though forming committees is an approach many CDI managers and directors are familiar with, Motsinger also suggests using some less conventional and more fun methods to instill a team atmosphere across the system.

“We did a summer retreat event. We took the ‘Strength Finders’ survey by Tom Rath because I wanted people to understand that even though people worked differently, it didn’t mean they were working wrong,” says Motsinger. “Everyone took the test and read the books, and I had an HR representative come and talk to us. Then we all did activities to cement the content of the book. It was a time of self-realization to find out how you work and how your neighbors work.”

Though a staff retreat will definitely help team members get to know each other and build relationships across facility lines, employing personality tests can help staff feel that their individual strengths matter to the CDI program as a whole; it can also help the manager or director identify areas in which each individual staff member will thrive. For example, an introverted staff member may not be as adept at teaching groups of physicians as an extroverted one, but they may be quite good at educating on a one-on-one basis.

Motsinger warns, however, that using the personality tests only works with follow-up efforts from the manager or director. If the team members take the tests, talk about them, and then forget they happened two months after the retreat, they won’t yield anything substantial. The staff profiles are also on Motsinger’s bulletin board for easy, transparent reference.

“We went back six months later and I had them break out in their steering committee, and I gave them an exercise that would help them understand their strengths. It wasn’t that we just did it and then forgot about it,” Motsinger says. “It was a really good exercise and shed a lot of light on where people are.”

Having those follow-up meetings and exercises reminds the team of their own strengths and the strengths of their fellow team members. Those reminders serve as a memory jog for CDI staff when they run into trouble in their day-today work. And, when questions do arise, they feel comfortable reaching out across facility lines for help and advice.

“We have a lot of people who work really hard,” says Motsinger. “That’s really what has fostered this team-centered environment.”