Guest Post: Individual effort equals organizational success
by Sylvia Hoffman, RN
The role of the clinical documentation specialist has been in a state of flux for the past few years. We wear many hats including that of nurse, coder, teacher, auditor, statistician, politician, and sometimes therapist. How many times have you had to evaluate the mood of a doctor prior to discussing a documentation issue, or been caught up listening to their problems in the office or with a colleague. The job description is constantly shifting.
Our profession has faced changing DRG’s, dealt with the complex nuances of the query process, and the avoidance of “leading queries.” There are additions to the list of Hospital Acquired Conditions, to contend with, concerns about Recovery Audit Contractor reviews, and the advent of ICD-10 to worry about. And that’s not to mention the transition and implementation of Electronic Medical Records.
During these stressful times, it has become apparent that CDI specialists are resilient, intelligent, resourceful, and indispensable! With these changes however comes stress. An article from MED Indiana, on Life Stressors That May Lead to a Cardiac Event listed several stress factors that may be faced in the clinical documentation workplace. They include:
- Changes in work hours or conditions
- Trouble with your boss
- Change in work responsibilities
- Change in work
- Major business readjustments
These situations may sound familiar to you and since most CDI specialists tend to be “long in the tooth,” or seasoned, as they say, we may be more affected by changes than most. This is one of the reasons that the Association for Clinical Documentation Improvement Specialists (ACDIS) organization is so important, for it gives us a forum to communicate, commiserate and share business practices throughout the state. It is a source for education and team building. A presentation at the 2009 National convention titled Restarting or Revamping Your CDI Program: A Case Study by Catherine O’Leary and Colleen Gary discussed various issues relevant to a CDI programs such as:
- How to hire the right team?
- How to retain your team and provide motivation? And…
- How to measure success?
One major issue addressed in the article seemed to be staff turnover. Not everyone can do this job and not everyone enjoys CDI work. It can be a thankless job. Occasionally we are perceived to be in the adversarial position of “Chart Police.”
The Clinical Documentation Specialist role should be well defined and program goals should be set and if needed, reset, again and again. Ongoing education and growth is fundamentally necessary in all professions and CDI is no exception. Involvement in ACDIS and other educational forums helps us get up to date information regarding our profession. And it helps prevent stagnation and boredom.
The experience of our membership is varied: Some have been working in CDI positions for many years in well established CDI departments and others are new and developing their programs from the very start. We need to reach out and help newcomers and they in turn can then help others that join our group in the future. There is strength in knowledge and there is strength in numbers. The ACDIS organization has the potential to someday have a major role in setting CDI policies and protocols.
In the words of Vince Lombardi: “The achievements of an organization are the results of the combined effort of each individual.”
Editor's note: Hoffman, at the time of this article's release, was a CDIS in Tampa Florida. She has been a nurse for more than 20 years and enjoys writing, painting, and travelling.