Radio Recap: Standardizing CDI across 60 facilities

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Back in 2013, when James Wall, RN, BSN, CCS, joined the organization, LifePoint’s nearly 60 facilities had a hodgepodge approach to CDI efforts. In fact, only 10 even had CDI programs in place and of that, five were staffed in-house, from within the hospital, and five were staffed by outside (vendor) sources, Wall explained during the December 14, 2016, episode of ACDIS Radio.

Wall made finding vendors to help them streamline CDI efforts, provide software, education, and post-implementation assessments of CDI program efforts his first priority. Different CDI programs likely need different benchmarks due to patient volume, patient type, and productivity goals. However, establishing basic expectations for program and staff helps standardize processes system wide and allows the administration to evaluate both the system’s progress and the individual CDI professional or physician’s progress. For LifePoint, the CDI benchmarks included:

• Open/review rate of 98% of records on the day received
• Follow-up record reviews conducted daily
• Less than 10% CDI/coder DRG mismatch rate

The average length of stay for a patient at LifePoint is three-to-four days, so Wall wanted CDI staff to look at that record two-to-three times after the initial review. This allows the CDI team to keep track of the record and any changes to the diagnosis and/or treatment during the patient’s care rather than leaving the entire review until the end of the patient’s stay. The final benchmark relates to this as well. At the end of the day, the DRG should be a 90% match with the final coding selection. Since reviews are conducted throughout the patient’s stay, there should be little disagreement at the end, Wall said.

Many programs set query rate benchmarks. Wall, however, described his experience with query rates as “less than satisfying.” Putting pressure on CDI specialists to submit a particular percentage rate of queries results in poorly constructed clarifications lacking strong clinical indicators.

LifePoint expects physicians to respond to 95% of CDI queries. “This is not an agreement rate, just a response rate,” Wall said. Additionally, physicians at LifePoint have 24-36 hours to answer the query.

Because documentation clarification needs to happen quickly it is “paramount that CDI staff and physicians talk well together and there is a good rapport between them – in a collegial way,” he added.

Because many of the facilities in the LifePoint group did not have CDI programs in place when he started, Wall did not have to fight many legacy systems or preset notions of how CDI efforts should be run. When those legacy systems and ideologies become roadblocks, however, Wall suggests simply having a specific date on which previous CDI methods are grandfathered out and new processes are implemented unifying the various systems. For example, LifePoint eased this transition by providing a library of queries (113, to be exact) that already followed all its new guidelines and processes.

Ultimately, Wall stated that, no matter which software and education systems you choose, the benchmarks are the most important factor to focus on. First, the benchmarks should all be realistic and achievable. Second, the CDI professionals should be empowered through the system and be a part of benchmark implementation rather than feeling like a victim of any changes in outcome expectations.

Although some portions of software and education can be easily standardized, Wall admitted that other aspects, such as facility culture, physician buy-in, and regional coding practices are more difficult to standardize. Where possible, though, standardization will ultimately help your system reach its potential.

At the end of the day, Wall said that fully standardized CDI programs will be “how they [the hospitals/medical groups] become optimized.”