Q&A: PSI review structure
A: For CDI programs that have CDI staff reviewing patient safety indicator (PSI) cases, how are PSI reviews set up? Do you have a dedicated CDI staff member for these reviews? Is it a shared task among the group or is there a PSI team? Do you meet regularly with the quality team, and if so, what is the cadence? How many cases are reviewed monthly? How involved is coding in these reviews?
Response #1: We have four CDI specialists reviewing hospital-acquired conditions (HAC) and PSIs as well as some mortality cases. These CDI staff have a split FTE that we reevaluate each year. Currently 0.2 of their FTE is dedicated to this work, so their monthly productivity expectations with normal reviews are 20% less than the rest of the team that are at 1.0 FTE. This allows them each roughly 8 hours per week for this work. Some weeks they spend less, other weeks they spend more. These cases can take our team quite a bit longer to review, but having four team members also allows coverage during paid time off and leave of absences.
These reviewers do meet with a quality representative. In the beginning, they were meeting weekly, then it moved to monthly; now the quality representative is there about quarterly unless we reach out with a need. For 2025, we are looking for a better communication pathway as these cases are reviewed in real time rather than once a month. For 2024, our average monthly has been 44 per month.
We work with the coding department frequently on these cases to help with changes to the coding identified through the CDI review or because of queries. We do not meet with them on a certain cadence, but the team emails them and discusses every finding or opportunity identified.
Response #2: At our organization, all of the CDI team reviews all PSI cases. We have a team in our leadership and quality department that gets notified once one is identified and a dedicated quality CDI staff member who assists the team with finding exclusions. We may see about 20–25 per month as a rough estimate.
Response #3: Our PSI cases are reviewed by all CDI specialists as they review each record and/or see the alert in the CDI program during the record review. They look for any possible exclusions to capture in their coding or query for them as appropriate. We currently have a trial at two facilities to have the CDI specialists send notification of their PSI review and any exclusion query they have sent to our supervisors to verify/review, which they forward to the facility CMO, physician advisor, and quality manager for real-time, in-house notification.
Other facilities that are not involved in the real-time notification of PSIs continue with our normal practice, which involves the CDI specialist identifying a confirmed HAC/PSI related to a catheter-associated urinary tract infection, central line bloodstream infection, or surgical site infection, then sending a notification to our infection prevention/control practitioner for that facility. We do not meet with the quality team regularly about PSIs but have provided them updates on findings and totals for the real-time notifications and any exclusions CDI staff identified to remove the PSI for reporting. Our coding partners are not involved in either process at this time.
Response #4: We started a concurrent review process for PSIs. It took a year to phase in all of PSI 90. We started with PSI 13, then three months later added PSI 11, and then added one PSI per month until we covered all of PSI 90. The frontline CDI specialists are responsible for identifying a possible PSI, either based on the situation or the PSI flag in our EHR system. They notify the CDI coordinator who does a more in-depth review for inclusion and exclusions. If we are unable to exclude the PSI, we route the account to our physician advisors for them to review from a provider perspective. When we started with this, it was the frontline CDI specialist who reviewed for any exclusions, but we found that was taking too much time and preventing them from doing reviews. Sending them to the coordinator for review was a more efficient process, as the coordinators were able to become subject matter experts on the Agency for Healthcare Research and Quality technical aspects.
Prior to this process, all PSIs were reviewed post-coding by the coding manager. The coding department still reviews any PSIs that were not identified concurrently and also the PSIs for obstetrics, which we do not review yet.
Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council. For the purposes of this article, all Council member answers have been deidentified.