Q&A: Staffing ratios

Q: We currently use a staffing ratio of one CDI specialist to 1,900 discharges, but I feel this is very outdated as we are now doing quality and clinical validity. Will anyone share your ratios that their CDI also covers quality and clinical validity and at times DRG appeals?

Response #1: We use a ratio of one CDI specialist to 1,500 discharges. We were able to double the number of FTEs once our director started and was able to show a return on investment and/or risk to the system with not having appropriate staffing levels. 

Our team members are responsible for

• Recognizing PSI 90 and submitting appropriate queries on these with guidance from our CDI coordinators
• Recognizing mortality cases or transfer to hospice patients and appropriate queries with guidance from the CDI coordinators
• Submitting cases for second level review
• Reviews and queries from coder requests
• Clinical validity on top diagnoses at risk for payer DRG downgrade
• Risk adjustment (top 10 Vizient)

Response #2: We have 13 CDI specialists for our four campuses, all working remotely to cover roughly 800 beds. We participate in concurrent inpatient reviews and selected retrospective reviews working to attain a severity of illness (SOI)/risk of mortality score (ROM) of 4/4 is possible. We also escalate queries to the medical directors and provide one-on-one physician education after case closure. We confer with our coder partners for mismatches and full reconciliation.

Our additional two team leads and one educator complete physician education at orientation and 90 days follow up at selected specialty/division meetings. They also provide post-coding, pre-bill audits for high denial cases, provide appeal letters for clinical validation DRG downgrades, confer with a physician advisor for additional appeal processes, and provide random audits for CDI reviewers. We complete mortality reviews and report PSIs to our patient safety colleagues if we’re not able to query to avoid.

Response #3: Our staffing is based on 1,500 discharges per CDI specialist. Our team is involved/responsible for all the following:

• PSI identification and query
• Mortality reviews (CDI lead is primarily responsible, but the team works to ensure ROM is at a 4)
• 100% CDI/coding reconciliation
• All queries (including clinical validity) and follow up, including escalations to the medical director as needed
• Attendance at service line meetings
• Participation in appropriate hospital committees with education provided as needed

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.