CDI Week 2021 Q&A: A full menu (productivity)
As part of the eleventh annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Hiral Patel, MHI, BSN, RN, CCDS, CDI specialist at University of Texas Southwestern Medical Center in Dallas, Texas, answered these questions. She is a member of the Texas ACDIS local chapter and of the 2021 ACDIS Furthering Education Committee. For questions about the committee or the Q&A, contact ACDIS Editor Carolyn Riel (criel@acdis.org).
Q: This year’s CDI Week Industry Survey includes questions on productivity for the first time. (ACDIS’ last look at productivity “Set CDI productivity expectations, but don’t look for a national standard” published in 2016.) Why do you think it is important for information like this to be gathered and made available? Why is it important to know how your CDI department (as well as yourself as a CDI professional) compares to national averages?
A: I think it is important for information like this to be gathered and made available so that organizations can use the survey data to get an idea of where their organization stands compared to all the other organization in the nation. It is very important to know where your CDI department (as well as yourself as a CDI professional) stands compared to national averages because the numbers will give us an idea and help us know where other CDI departments are and can also give us an estimated benchmark to go off of. The national averages help organization gauge the success or failure of a CDI program.
Q: Most respondents (57%) say they review an average of six-10 new records per day—with roughly the same amount (54%) say management expects them to perform six-10 new reviews per day. Being that a similar percentage of respondents say their expected and actual chart reviews per day are in this range, do you think these ranges for new reviews per day are good standards for the CDI industry to hold? Are there risks with having set standards for productivity for the CDI industry as a whole?
A: I think these ranges for new reviews per day are a good standard because you should be able to review the new patients together with your re-reviews so that all patients can be reviewed on time before they discharge. At my current organization, we are required to do 10 new records per day, which is within the average range of six-10 new records per day per the survey. This way we are able to balance the number of new reviews and re-reviews better.
I do not think there are risks with having set standards for productivity because having a set standard helps the CDI program to gauge their success. Having set productivity standards also helps organizations to have a way on how to gauge a CDI professional and hold them accountable for their job responsibilities.
Q: Do you feel it is important to have a set range of expected chart reviews per day for staff? Should this range be the same for everyone in a facility, or does it need to be customized for each CDI specialist?
A: Yes, I think it is important to have a set range of expected chart reviews per day for staff so that we can know what should be done daily. This also enables equality within the department with everyone doing the same number of reviews. This does not increase the workload for one person compared to everyone else. I think the range should be the same for everyone in a facility because this promotes equality within the organization. The only time this range should be customized to each CDI specialist is when they are in orientation and getting trained because at this time, they may not be able to reach the daily required range as they are learning. After the orientation period, the CDI specialist should be responsible for the set range for the organization.
Q: If a CDI specialist is not meeting productivity expectations in your facility, what next steps are taken? According to 68% of respondents, the CDI manager will meet with them for a one-on-one discussion, and 22% say if it goes on for an extended period of time, the CDI specialist may be let go. What other steps do you feel should happen between that one-on-one discussion and someone being let go?
A: If a CDI specialist is not meeting productivity expectations in my facility, the manager would have a one-on-one discussion with CDI specialist to find out what issues the CDI specialist is facing if any and make an action plan from there. The coordinators would then help the CDI specialist in places they need help so that they get on track. I think after the one-on-one discussion, the CDI specialist should be given a chance to improve and receive more education, if needed, and have their productivity monitored for some time before letting them go. They may need a little more time and education to get up to speed to the required standards.
Q: One outcome of not meeting productivity standards could be for those working remotely to be asked to come back onsite until they meet expectations consistently, according nearly 20% of survey respondents. Has your organization implemented such contingency plans related to remote/hybrid work and productivity? What benefits has your organization seen related to remote/hybrid CDI efforts? Does your organization help remote/hybrid staff with technology implementation either through reimbursement or stipends to offset costs for equipment or internet infrastructure at home?
A: When I joined my organization, they were 100% remote due to the COVID-19 pandemic and therefore, at that time there were no such contingency plans in place. Before the pandemic, however, the staff was allowed to work remotely one day per week as long as they met their productivity standards. If they did not meet the standards, then the privilege of working remotely was taken away until they met the standards again. Working in the remote/hybrid setting has helped my organization have more positivity towards the work done by the staff and our productivity numbers have been really high.
My organization does not help offset costs for equipment or internet infrastructure at home, but they provide the staff with the equipment for us to work remotely. If we have any issues, then our IT service desk would help solve issues with the equipment so that we can do our work without issues. Generally speaking, I feel remote CDI has a positive effect on productivity because the staff does not have to deal with traffic to and from work or have to waste time looking for a space to work as we do not have designated office spaces at my organization.
Q: Only 6% of respondents noted remote work due to COVID-19 decreased their productivity. What effects, if any, did your CDI program see in terms of productivity related to the pandemic? Has your CDI program returned a pre-pandemic “normal” now? What changes did your organization implement related to CDI during the outbreak that it intends to maintain going forward (if any)?
A: Our CDI program actually had a higher census during COVID-19 and the productivity was actually high. Our CDI program has returned to a hybrid setting with three days on site and two days remote at the moment, which is the new normal at this point for us. During the outbreak, my organization made the CDI program fully remote, but does not intend to have a 100% remote CDI program at this moment.
Q: A large portion of respondents mentioned not having certain technological solutions (52% do not have a quality database, 51% do not have computer-assisted physician documentation, 42% do not have internally developed EHR modifications, etc.). What role do you think technology plays in CDI productivity? Do you feel technology is an aid or hindrance to productivity? Why? How does technology affect productivity in your facility?
A: I think technology plays a very big role in CDI productivity because almost everything is digital now. We do all our reviews electronically and communicate with physicians electronically most of time, which would help with productivity because you do not have to go looking for physicians or turning pages of paper charts to find anything. Technology helps make our work easier. I feel technology is an aid to productivity and not a hindrance because it has made life easier. You can get everything is one place without having to go to different locations physically.
Q: More experienced CDI staff are more productive, according to survey respondents, 62% of whom noted that the experience of the reviewer had the largest effect on CDI productivity. What steps can a CDI professional take to increase their experience and therefore improve their productivity? How long do you think it should take a new CDI specialist to become proficient in their role? In your opinion, can one-on-one staff mentoring, or CDI/coding collaboration, improve a CDI specialist’s record review capabilities?
A: For a CDI professional to increase their experience and productivity, they need to keep learning and trying to keep up with the new guidelines, and information published daily as healthcare keeps changing daily. Also, they need to always ask questions if they’re not sure of something, which would help them increase their knowledge and make them more proficient as they keep learning.
I think it should take at least two years for a new CDI specialist to become proficient in their role because this is also the set minimum time required by ACDIS for one to achieve the CCDS certification. In my opinion, one-on-one staff mentoring, or CDI/coding collaboration can improve a CDI specialist’s record review capabilities tremendously because of the constant feedback received while doing one-on-one mentoring. The CDI/coding collaboration helps CDI staff learn more about coding, which helps the CDI specialist to capture correct codes and have less DRG mismatches.
Q: Some 22% said verbal (versus electronic) querying had the least impact on productivity. Being that respondents noted verbal versus electronic queries as not making a major impact on productivity, what do you feel are the benefits to each? How about pitfalls?
A: I think both means of querying have their own advantages and disadvantages. Verbal queries are a great way for physician engagement and also being able to talk to a physician face-to-face about complex patient scenarios that are hard to explain electronically. On the other hand, electronic queries are easier for physicians to answer as they have the question and choices to read from and provide a response from there. Electronic queries can also save time of trying to get a hold of a physician, which will impact productivity as you may not be able to reach the set range of reviews.
Electronic queries can be answered by the physician at their convenience, which would increase the productivity by having a higher response rate compared to verbal queries because after the conversation, you have to wait for the physician to update their notes, which they may not get to in a timely manner. This would drop productivity numbers with more no responses because if it is not documented, it was never done. The pitfall of verbal querying is the amount of time spent looking for a physician and then waiting for them to update the record. The pitfall of electronic querying is that you have less physician face-to-face interaction.
Q: What factors do you feel are the greatest obstacles for CDI productivity, generally? Should factors outside of work (i.e., family life, etc.) be taken into account when setting productivity expectations? Why or why not?
A: I think the greatest obstacles for CDI productivity is physician engagement because we are very much dependent on them for our query rates. Also, the documentation by physicians makes our work either difficult or easier depending on how the physician writes their notes. I do not think factors outside of work should be considered when setting productivity expectations, because one should distinguish between work life and family life and give their 100% at work. This enables everyone to be treated equally with equal expectations. I think work is work and family is family, and should never be mixed in my opinion.