Podcast insight: March 15 episode discusses how to make audits non-punitive

by Joshua Raposa

CDI audits are not only important for establishing and promoting compliancy standards, but they are also crucial for professional growth, according to educator Ella Elizee, MSN, RN, CCDS, a CDI educator, and Joanne Mullins, DNP, MSN, RN, CCDS, team leader and internal auditor, both at Tampa General Hospital in Florida.

While it’s normal for CDI audits and competency assessments to focus on productivity and query rates, Elizee and Mullins argued that these are not the most important aspects of an internal audit.

“A CDI audit focuses more on quality. When performing individual CDI audits,” Mullins said on a recent episode of the ACDIS Podcast, “we evaluate for both strengths and areas for improvement. The feedback when becomes personality and specific to the CDI’s needs.”

An internal audit is intended to improve the quality of a CDI professional’s performance, which thereby increases the accuracy of clinical documentation. As a result, it raises the likelihood of high-quality patient care. Through auditing and the reassessment of new and core competencies, CDI specialists are able to garner the knowledge necessary to provide the most precise documentation and information for treatment decisions.

“We have several different types of focused audits internally and then we also have audits that focus on our organizational priorities. So, as the industry changes, our current practice of auditing will need to adapt to include those changes, such as social determinants of health, risk adjustment, laterality, and so forth,” Mullins said.

At Tampa General, educating CDI professionals on new regulations and compliances, like common deficiencies, low weighted DRGs, and diagnoses that are at high risks for denial, has been critical for keeping up with the fast-paced nature of the CDI world and, most importantly, providing accurate and complete documentation for the patient.

Of course, they noted that at their facility and elsewhere, the term “audit” generally carries with it a potential fear and cause for concern; however, Elizee and Mullins insisted that CDI audits are inherently educational and non-punitive in nature:

“It is important that you create a supportive and non-punitive environment where our staff feels comfortable discussing in the areas of weakness or working together to identify solutions,” Elizee said. “By fostering a positive attitude towards these processes our CDI department can really help to build a culture of continuous improvement and ensure that staff are equipped with the knowledge and skills that they need to succeed.”

Editor’s note: Raposa is an associate editor at ACDIS, which is based in Middleton, Massachusetts. Contact him at jraposa@acdis.org. This article is a recap of the March 15, 2023, episode of the ACDIS Podcast.