CDI Week 2021 Q&A: Managing your kitchen staff (staffing, professional development)

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. Lora Diner, RN, CCDS, CDI manager at Centura Health in Centennial, Colorado, answered these questions. She is a member 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: Most 2021 CDI Week Industry Survey respondents (47%) said they entered CDI because they wanted to grow professionally, and CDI offered them a chance to do so. What was your initial reason for entering CDI? What career growth opportunities have you had or seen since being involved in CDI?

A: I entered the CDI world in 2010 as the program was just starting and evolving in the hospital I worked in. I was a charge nurse for many years on a busy multi-trauma floor and wondered what the happy lady who came to the floor every day searching through charts was doing. She told me about CDI and that they were hiring. I did a day of shadowing her and decided that this job sounded very interesting. I was at a point where I was ready for a change from bedside nursing, and this was a position that could fulfill that. Our facility was the first to go live with a CDI program in our large hospital network. I was able to attend my first ACDIS conference in 2013 in Nashville.

I have had tremendous growth opportunities in this career. I have worked as a CDI specialist, CDI supervisor, CDI lead, and I am now the CDI manager. Our department has grown over the years to include a CDI quality liaison position and CDI specialist, level IIs. We have developed a career ladder to promote our team to continue to grow in this CDI role.

Q: According to the survey, 19% of respondents entered CDI because they were involved with a different department and were asked to fill a CDI role. Additionally, 36% said their CDI department includes those with an HIM/coding background in their department. Do you feel it is important to have people involved in CDI with a non-traditional background, such as coding? What potential opportunities do you think might be missed if CDI programs staff the department with only one background type (i.e., physicians, floor nurses, or inpatient coders only)?

A: Our CDI department is consistently staffed by RNs. Our experience with having a coder as part of our CDI team was not efficient. We work closely with our coding service team and this partnership has been working. We have established monthly meetings where we discuss all sorts of topics. We are consistently working on developing this working relationship. We have also included a CDI quality position that incorporates a RN who is a CDI specialist as well and that person works closely with quality and reviews patient safety indicators and hospital-acquired conditions. We also have a medical director and HIM director over our CDI department. I feel our department has benefited from joined partnerships with these ancillary departments while keeping the CDI specialist roles as RNs only.

Q: According to the survey results, 79% of respondents noted their organization has a written policy requiring a clinical credential (i.e., RN, MD, etc.) for their CDI department. Does your organization have written policies about credential types required for a CDI specialist? How were these policies decided?

A: We have RN credentialing in our job descriptions. Presently, we do not have a written policy. We encourage CCDS certifications for our staff but do not require it at this time. I believe the benefit of having RNs in this position is their clinical knowledge and experience talking with providers.

Q: Roughly 19% of respondents said they have foreign-trained medical graduates in their CDI department. Why do you think foreign-trained physicians might be drawn to the world of CDI? What unique knowledge or narrative do foreign-trained medical graduates bring to a CDI department?

A: In my opinion foreign trained medical graduates (FMGs) bring a unique knowledge as they hold a clinical degree from their original countries along with their clinical acumen.  I think they might be drawn to CDI as a way of using their clinical acumen and understanding that it could be years of preparation for exams to pass the United States certification. Many decide to not to pursue a United States medical license and want to apply their skills elsewhere.

Working with physicians, working with their peers, applying their medical knowledge and awareness of a physician’s workflow has helped in the feeling of a connection of taking care of patients while being involved in quality and documentation.

Q: Most respondents (34%) said they have zero to five CDI specialists on staff at their organization. How many CDI professionals do you have on staff at your facility? How about systemwide? Does this feel like an appropriate number of staff for your organization’s needs?

A: I am part of a large healthcare organization with 15 facilities that we do reviews at. We have a total of 30 CDI professionals across the system. Each facility has one to five CDI specialists depending upon the volume, size, and service lines at each facility. We figure our FTEs by discharges. We follow 1,900 discharged patients per FTE (we exclude newborns, OB, psych, and rehab). We prioritize our reviews by payers. Our team consists also of three team leads, two educators, and a dedicated CDI quality position. I believe we have adequate staffing to review charts, send queries, and communicate with providers, including a monthly physician champion meeting at each facility. We continue to be facilitators of communication of patient care.

Q: Just under 20% of survey respondents said their CDI program does not offer any professional development opportunities. Does your department offer professional development opportunities? If so, what are they? Which types of professional development opportunities have you found most beneficial personally?

A: Our department offers quite a few development opportunities. We offer five CDI specialist a year the option to attend the annual ACDI conference. Our organization has tuition reimbursement, so our team takes advantage of using these for ACDIS Boot Camps, and CCDS training and testing. We also encourage our team to participate in our quarterly Colorado ACDIS local chapter meetings. Within our department and through our CDI vendor we have monthly education sessions. I have found all of these to be beneficial personally. This profession is constantly changing; if we don’t continue to learn and grow, we will remain stagnant.

Q: In your opinion, what risks do CDI programs face in not offering staff development opportunities? What advice would you give to an organization with limited resources seeking to provide some type of professional advancement or development opportunity to its staff? What advice would you give to CDI specialists seeking professional development opportunities in an organization that does not offer them?

A: I feel there are many resources related to our field that do not have to come through your specific organization. For example:

• ACDIS national and ACDIS local groups
• Tuition reimbursement to be used to attend education sessions
• Online webinars and education sessions

My advice is to try to connect with another CDI group or get online and search for professional growth opportunities for CDI professionals.

Q: The majority of respondents (60%) noted that their department hired new staff in the last 12 months. In your opinion, what might be contributing to this growth? Should CDI departments always be looking to increase their staff, or is there ever a point where staffing needs should be met? Did your organization hire new CDI staff in the last 12 months? How has that affected your department’s focus, productivity, and program structure?

A: I think COVID-19 has affected nursing jobs at the bedside. From our interviews over the last six months, people are looking for a job that are outside bedside. I believe nurses are worn out, after the past year and looking for a job that might be less physical. I also believe that hospitals continue to expand and implement CDI programs. I think looking at staffing is necessary at least yearly and evaluated. We did hire new staff in the last year.

Our focus continues to be obtaining appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. To educate members of the patient care team regarding clinical documentation guidelines and regulatory requirements, including attending physicians, allied health practitioners, nursing, coding, and case management. To support timely, accurate, and complete documentation of clinical information used for measuring and reporting hospital and physician-based outcomes.

Our productivity has remained about the same. Our team was sent home to work remotely during the pandemic and were able to continue their reviews. Our program structure was affected over the past year, regarding CDI specialists working remotely. One of our organizational goals is physician facing, and with the pandemic our CDI specialist have not been able to have the strong physician interacting due to not being onsite. Our goal is for the CDI specialists to be back onsite in the facilities.

Q: Is there a relationship between the rate of new hires and the “new normal” effects of the COVID-19 pandemic, in your opinion? Do you believe that the CDI industry fared better than some other healthcare related fields in terms of maintaining program integrity? What are your own hopes related to CDI growth post-pandemic?

A: Our department sent our CDI staff home to work remotely during the pandemic. Our associates were able to continue to do reviews as normal. We did take a break from our physician champion monthly meetings and were more diligent about sending queries to our physicians recognizing they were extremely busy with acutely ill patients.

I do believe the CDI programs did fare better than other health-related fields. Charts still needed to be reviewed and with the new COVID-19 codes and new documentation, our staff was able to educate the physicians as well as capturing the new codes for the integrity of the charts. My hope is that our department and the CDI industry as a whole will continue to grow and expand.