Q&A: CDI productivity
Q: As we plan to update our CDI productivity policy, I wanted to check how others calculate their productivity. Do you include initials (new accounts), subsequent (in-house re-reviews), and Retro (Discharge accounts, mainly to reconcile queries)? Or just initials (new accounts), subsequent (in-house re-reviews)? What is the total productivity expectation per day (e.g., 20, 25, etc.)?
Response #1: Our productivity calculation includes initial, concurrent, and retrospective reviews. The reasoning is that each review requires time spent by the CDI specialist, even if it is for a few minutes, and they should be recognized for it. We do pre-bill holds, so the team is very involved in reviewing the charts on hold, and they work fluidly with the coders.
I also run my data on a monthly basis, as I don’t think a daily productivity rate is ideal in the CDI world. Things vary day to day, depending on the types of charts the individual is looking at, the number of queries they have to send, etc.
The productivity expectation is 80% of the standard 30-35 reviews per day, which leads to 24-28 reviews per day. The 80% takes into account if there are meetings they need to attend, any downtime they may encounter due to system updates, etc.
Response #2: We have actually removed standard productivity measures for a specific number target. I’ve discussed this with several other CDI leaders that have done the same or who are taking a different approach to productivity. Now may be the perfect time for your organization to consider this as well.
I define productivity by the meaningfulness as a contribution to the CDI’s goals. Included in that evaluation are reviews (initial, follow-up, and retrospective), query process (creation, follow-up, escalation, closure, impact capture), DRG reconciliation, and notifications/discussion with coding, etc.
Although it’s not measured based on a standard number, we average 25-35 reviews per day, sometimes more.
Response #3: Our productivity encompasses new and subsequent reviews. Each CDI specialist is expected to reconcile their cases (validate the query impact and evaluate the final DRG assigned by coding). We have a structured initial and subsequent review template that we use as well as structured query templates. There are many factors that are considered in our “numbers.”
Our staffing is based on 1,500 discharges per fulltime equivalent (FTE). One FTE would complete a minimum of 1,200 cases annually. We expect initial reviews within 24 hours of admission and subsequent reviews at least every other day. Each CDI specialist manages the case from admission to discharge, we do not hand off cases to other CDI specialists. New CDI specialists with no prior experience would be expected to do six new cases per day after the first three months. We also expect our CDI staff to do some rounding with clinicians and physician advisors. The work the CDI specialists do is in the concurrent space, we do not routinely do discharged cases. Productivity is considered in evaluations and when ranking CDI specialists as high, solid, or low performers.
Response #4: For initial reviews, we base our daily/weekly/monthly productivity off of hours worked. Taking into consideration, paid time off, holidays, and time we allocate for professional development, one FTE should have 1,940 hours per year allocated to “productive time” for case reviews.
Our expectation is one initial review per hour worked, so based on 52 weeks for the year, that is 38 initial reviews per week. To make our accounting a bit easier, we have rounded that up to 40 initial reviews per week (eight per day) for a FTE. This rate also standardizes calculations if you have variable FTEs or shifts. We do have some 0.8 FTEs and staff that work eight- or ten-hour shifts, so making it a 1:1 ratio is simple for all to keep track of.
For subsequent reviews, we base it on the number of initial reviews completed at a rate of 1.5. For example, the reviewer completed 100 initial reviews for the month, the expectation is that they should have completed at least 150 subsequent and retrospective reviews (combined). Until this year, we did not include retrospective reviews in the tally, because we really wanted a bulk of that work to be completed in the concurrent space. But we do acknowledge that there is value in doing retrospective reviews so this year, we will give “credit” toward productivity for time spent in those cases. However, the majority should still be taking place concurrently with subsequent reviews.
In total, for an eight-hour shift, our staff should complete:
- Initial reviews: Eight per day or 40 per week
- Subsequent/retrospective reviews: 12 per day or 60 per week
- Total: At least 20 per day or 100 per week
I have found that what we consider “reconciliation” and what others call reconciliation varies. In our new workflows, the front-line review staff does not have to do very much in the way of reconciliation. In our current workflow, our CDI reviewers apply the query impact at the time of query response. The CDI leaders complete a post-bill “reconciliation” process in which we audit and validate assigned query impacts, baseline principal diagnosis selections, etc. to ensure our financial reporting is as accurate as possible. Our coding team also completes something they refer to as reconciliation, which is DRG reconciliation between CDI and coding which includes a pre-bill DRG mismatch process.
We also have productivity targets for total clarification rates (minimum of 26%) that the CDI specialists are expected to achieve. We have a rather detailed dashboard/scorecard that we maintain for each CDI reviewer that provides performance ranges for all of the targets with a scoring system in addition to agreement rates, response rates, and a breakdown of the different types of impacts. This ensures those who exceed the minimum productivity standards are recognized appropriately for performance. This also helps leaders ensure we are evaluating all of our review staff fairly against the same standards and is a tool for identifying and coaching those that might be underperforming. We complete this dashboard on a monthly basis.
Response #5: Since we do not work the weekend, Mondays are very busy with the goal of opening new cases. We try to open 15 new ones per CDI specialist. We can then do some follow-up if time allows. Every other day we focus on opening at least eight new ones and then complete follow-ups with a goal of reviewing 20 cases per CDI specialist.
We have taken the reconciliation process away from the CDI specialists and have one person reconcile all cases. We just implemented this in the fourth quarter of last year and it has been a win for the team. Some of the CDI specialists were spending way too much time trying to reconcile the case while corresponding with coding and leadership. Removing reconciliation has allowed the CDI team more time to focus on current cases.
Response #6: We took three months to evaluate the team and establish expectations specific to our team. Our CDI program operates under the quality umbrella, and our team does focus on quality items such as patient safety indicators/hospital-acquired conditions and mortalities, with some more detailed reviews of these items as cases are identified.
We have three levels that determine the achievement of the team member:
- Threshold = Meeting minimum requirements
- Target = Meeting team goals
- Stretch = Above and beyond expectations
We have established dashboards for each of the team members that are populated and reviewed by their assigned coordinators in a one-on-one session each month with the CDI specialists.
Supervisors address any team member below the threshold for productivity (focus on initial reviews and re-reviews) and overall query rate. Everything else is out of their control and utilized to guide self-growth or identify issues within the facility.
It’s important to note that not all CDI programs calculate their query rates the same way. Our overall query goals are established each year with a ranking of team members and selecting the midpoint for the target. Some of our hospitals have a higher query rate than others, but our CDI specialists are all held to the same metrics for annual evaluation and continuous trending.
Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council and originally appeared in the CDI Leadership Insider, the monthly newsletter for members of the Leadership Council. For the purposes of this article, all Council member answers have been deidentified.