Q&A: Metric expectations, reporting, and education
Q: I have a couple of questions regarding CDI metric expectations, reporting, and education for your CDI teams. I have been working on a CDI metrics report of the expected systemwide versus individual query rate, review rate, physician response rate, agreement rate, and expected daily reviews of a CDI specialist per day. I was wondering what you normally do when CDI specialists are underperforming? Do you send the monthly metrics report for the whole team to see—both the CDI team metrics and the individual metrics included—and/or talk to the staff members individually regarding their numbers (seeing what may be going on with work, at home, etc.)? Do you have specific improvement plans documenting that your facility follows when a CDI is underperforming? Additionally, do you have any suggestions for encouraging a CDI specialist to do more thorough reviews and to look for query opportunities?
Response #1: We share team metrics with everyone, and every CDI specialist sees their individual productivity metrics on a monthly basis. If the CDI specialist is underperforming, we coach and mentor, set and then reset expectations. If the goals are not achieved, they are placed on a performance improvement program (PIP) where a supervisor will coach them with continuous feedback over a set time frame. If sustained improvement is still not achieved, they will continue to move forward on the performance improvement program until a written, and final warning is issued followed by termination.
Sustained improvement is key here: if they slip back, they go right back onto the PIP. We meet with underperforming CDI specialists individually to identify time management opportunities when they get sidetracked; we have also made performance a part of the CDI specialists’ performance review metrics, and this has helped a good deal. It takes a lot of extra work for leaders, but ultimately either the staff member improves, or they decide this is not the job for them.
Response #2: My team is 100% remote. I send out positive quotes at least three times a week and have monthly one-on-one phone calls with my CDI team. I ask them questions outside of their work, such as “how is your family? How is your mom doing?” We have monthly team meetings where we have time to share what is going on with CDI and our hospital system. Our meeting for December covered our team’s accomplishment, as well as individual accomplishments; the leadership also let our CDI team know that their work has been acknowledged by other departments, showing them the impact they have had in the past quarter and previous quarter.
When I gained my current team, the morale was poor, and it took a long time to rebuild, so perseverance and open communication were vital. Unfortunately, there are also individuals that will never change; however, that should be expected. When I started, many on the team felt that they would be penalized for wrongdoing all the time: therefore, written expectations for the whole team were important.
Response #3: We have our quality assessment report and a template to document underperformance and other related issues. When a team member is underperforming, the CDI manager has regular talks with them to determine how we can help further the specialist’s program (sometimes it is just some distraction or lack of understanding of workflow); however, when it becomes consistent, then the staff is put in the performance improvement program.
I present the entire team metrics with no names (e.g., overall CC/MCC capture rate, overall query rate, physician response rate, agree rate, etc.) during our CDI meetings, and then the individual productivity metrics are shared with each person via email and SharePoint (only the individual and the manager can see these metrics).
When it comes to encouraging team members to do more thorough reviews, it's about education, advanced level CDI training, and understanding the team's capabilities and challenges. Before I talk to any underperforming staff, I like to do an audit alone, making sure that there are no query opportunities first, and then I will address the question of underperformance (in general) at the staff meetings. The reason I do these two steps is because, in the past, I have been told that a staff member is underperforming based on a lower query rate, and after digging deeper into the query rates, I couldn’t find query opportunities for the cases that the underperforming employee had reviewed.
Response #4: When one of my team members in underperforming, supervisors will have a one-on-one with the staff member to determine what may be causing the metric drop. We customize our improvement plan to each team member and their circumstance.
We show the facility results to the team, but do not show one team members individual metrics to other team members. Every CDI specialist has their own dashboard, and we speak with them monthly about their personal metrics.
We also perform real-time concurrent audits that identify if they have missed an opportunity. The coordinator will have that discussion about the opportunity and educate as required. Working with the underperforming team member to determine what is causing the issue has been successful. However, we have—at times—had to have another coordinator to sit with the team member and determine whether the issue is organizational, or related to workflows, or knowledge deficits.
Response #5: We develop actions plans for underperforming CDI specialists. Leadership has one-on-one monthly meetings with each of their team members to review metrics. All CDI specialists have access to their personal metrics, which show where they fall compared to the team median. Most of our team members are competitive, so seeing where they fall compared to the team is a motivator. During account validation, I will (on occasion) take a snippet of their impact and sent it to the team’s chat as a way to say, “Way to go!”
Response #6: For productivity metrics, we publish our staff’s metrics monthly for all to see. However, our staff has been very resistant to metric transparency because of a previous and toxic management style. So, we use their employee numbers when posting metrics: this way they know their productivity, but others do not. This is something we are slowly changing, but it takes time to work past fear. We also send individual quarterly productivity reports to individual CDI specialists. This is a longer report that includes a lot more data; so far, they have really liked the addition of these quarterly reports.
For underperforming staff, the initiative is individualized. At the beginning of the process, I share metrics and expectations, and discuss any self-identified barriers. From there, we come up with a plan to address those barriers and grow past them. I then follow up on a weekly or bi-weekly basis with updated personal metrics as we continue to work on improvement.
If nothing helps and I feel we’ve done all we can, they are placed on a PIP. However, they are aware that this will happen long before it does, and I try to use it as a last resort. The PIP is placed in their HR file for future employment opportunities to see, impacts their merit increase, and can have lasting results on their career within our system. So, it is not something that I jump to quickly without working hand in hand with them for some time.
Response #7: We have our coordinators conduct a monthly meeting with each of their team members to review staff productivity and metrics and identify any issues that have been contributing to lower performance. If a team member is underperforming below our threshold for two months in a row, the coordinator and supervisor discuss what the team member has identified as a problem and hold a “coaching” meeting to address possible solutions (further support, education, etc.). If performance does not improve, the supervisor will continue to meet with the team member in question for more disciplinary action up to and including termination. We also have coordinators conduct concurrent audits for missed opportunities.
Response #8: We have daily productivity logs that the team completes, which are visible to their teammates. This helps with both ownership/accountability and adds a little peer pressure. For the most part, however, the team consistently meets or exceeds productivity expectations. When a CDI specialist fails to meet the goals, we meet with the individual to get a sense of the barriers and see what we can assist with.
For example, if it's time management, our leadership team will work with them for a couple hours and give them insight into some time management strategies (e.g., set a timer for each review to avoid going too far into the weeds). In most cases, the individual discussion and time management will get the staff member back on track. If the issues continue to become ongoing, we start a more formal process of a documented coaching plan. This includes a written action plan of what the CDI specialist needs to improve on along with a commitment from leadership on how we will support them in that goal. We ask for regular communication on the progress of their daily productivity goals and explanations. We have weekly meetings to go over the progress.
If this plan doesn’t work, we move to a formal plan involving HR and include the possibility of termination if the CDI specialist is not able to improve and meet expectations. However, this has been a rare occurrence: only one staff member has moved to this step, and it was because they decided CDI was not right for them.
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.