CDI Week 2019 Q&A: Physician engagement

As part of the ninth annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Sarah Matacale, RN, BSN, CCS, a CDI specialist at Vidant Health in Middlesex, North Carolina, and a member of the 2019 CDI Week Committee, answered these questions. Contact her at sarah.matacale@gmail.com.

Q: Can you describe the engagement and collaboration of the medical staff at your organization in CDI?
A: I think overall, we have pretty good engagement and collaboration at our organization. The CDI and physician advisor programs have grown so much to adapt to the changes in the industry. Providers realize how important their documentation is and have formed a partnership with the CDI specialists and physician advisors to achieve the goal of creating a chart that reflects the quality and level of care received at the bedside. Our organization values the CDI/physician advisor program.

Q: According to the 2019 CDI Week Industry Survey, only 12.71% of respondents said their medical staff is “highly engaged.” Why do you think so many CDI programs have such trouble engaging the medical staff?
A: I think the biggest challenge with engaging providers is competing priorities. They are being pulled in so many directions. They are constantly receiving documentation focus requests regarding patient satisfaction, quality initiatives, mortality, etc. All this is on top of their primary focus of providing patient care. It can be very daunting to “relearn” documentation to reflect industry standards and priorities.

Q: What has been your biggest challenge and most successful approach with gaining physician buy-in?
A: TIME is the answer to both parts of this question. Getting the time we need to build rapport and convey the message we need is always a challenge. Providers are more strapped for time than ever before, so we need to be concise with our message. We need to keep in mind that we’re taking the provider away from the bedside, so we need to make that time count. Using what time we can get to pack the biggest punch, so to speak, is an invaluable component to gaining buy-in.

Q: According to the Industry Survey, 63.37% of respondents currently have a physician advisor or champion, and 69.32% of those respondents said their physicians are either highly or mostly motivated and engaged. Does your department have a physician advisor or champion? If so, what has been the result of that relationship, and how much time do they devote to the CDI department?
A: We are so very blessed to have a strong full-time physician advisor program. They are invaluable to our team in providing education to service lines, intervening with “uncooperative providers,” reviewing difficult cases and denials, tracking data, serving on various organizational committees, etc. They not only educate the providers but the CDI team as well. They are always current on industry standards and can lend us some clinical input when needed. They have formed relationships with the providers and CDI specialists, which has been an integral part of the organizational growth we’ve seen.

Q: Do you have uncooperative/unresponsive physicians, and how do you handle them?
A: Of course! Doesn’t everyone? Using respect and understanding (as much as possible), begin with a one-on-one conversation and/or email regarding the concerns. Since we have a diverse and organizationally active physician advisor program, we can solicit their help when dealing with providers. For the most part, we’ve formed relationships with our providers and know how to work with them.

Q: Do you have an escalation policy of sorts to deal with them? What does that escalation policy entail? 
A: At our organization, unanswered queries are a medical record deficiency. If medical records remain incomplete for two weeks, the result is medical staff suspension.

Q: According to the Industry Survey, roughly half (51.03%) the respondents have a 91%–100% physician query response rate and 2.43% of respondents don’t track the rate at all. Do you track that rate? Why or why not? How have you gone about improving your query response rate? What do you recommend to those looking to improve their own response rate?
A: We do track our query response rates for several reasons. It tracks and trends charting deficiencies with providers and within service lines that may open educational opportunities. It assists in tracking quality measures as well, which can further be scrutinized into specialty areas.

On the opposite side of the spectrum, tracking query response rates puts the queries themselves under the microscope. Are the queries too long and full of information that isn’t pertinent to clarify? Are we over-querying and providers are just tuning out?

While each organization has different views of what to send a query for, it is important not to over-query. This adds to provider burnout and dilutes the truly necessary queries that affect DRG assignment, reimbursement, quality measures, present on admission status, etc. Also, providers are pulled in so many different directions regarding patient care and documentation. Respect that time by crafting concise queries that contain all the data needed to answer the question without having to go back to the record or sort through “fluff.”

Q: When it comes to physician query agree rate, 61.87% of Industry Survey respondents have an 81%–100% agree rate and 4.11% don’t track that metric. Do you track physician agree rate to queries? Why or why not? What can that metric tell you about CDI’s efforts and success?
A: Tracking query agree rates can add a numeric value to the quality of the CDI team’s efforts, but it’s only a small part of the whole picture of what we do.

It’s easy to get caught up in following metrics as an indicator of success. There are a number of variables that need to be considered when looking exclusively at agree rates: physician engagement/buy-in regarding the importance of clean documentation in the record, industry trends that pull providers in a variety of directions with less time available to focus on queries, the quality of the query, and simply the disposition of the person answering the query.

A strong agree rate, however, does reflect a degree of trust between providers and the CDI team in documenting the care provided at the bedside. 

Q: Do you provide formal education to your physicians, one-on-one/informal coaching, or both?
A: Both are really important. Providers don’t all think, learn, and respond the same way to new information. Formal education and written materials hold value when a lot of information needs to be covered and may require practice or further reflection later.

One-on-one education can be invaluable in changing thought processes in a more personal way. It can build trust between the provider and CDI specialist.

Any and all education is good education. Being open to educational opportunities as they arise is key in this area. Always being knowledgeable, understanding, patient, and respectable keeps the lines of communication open.

Q: Could you tell us about an experience you had winning over a physician to CDI?
A: One physician? How about entire provider groups? Our CDI team has been asked by several service lines and provider groups to come in and review their charts, track their data, and educate them on quality documentation. Being asked to provide constructive criticism to improve quality is the biggest win I can think of. It benefits the providers, the health system, and most importantly, patient care. 

Q: How has the changing reimbursement and denials landscape affected the way you interact with physicians?
A: It has made the CDI message more complex and comprehensive. The focus shift to value-based purchasing changes the dialog from simply DRGs, CCs, and MCCs to Patient Safety Indicators, hospital-acquired conditions, risk adjustment, mortality, and more.

Q: Does your program regularly share CDI data with its physicians (either one-on-one or in group format)? Does your program leverage publicly reported data in its physician education? Why or why not?
A: We do not regularly share CDI data with physicians with regards to query rates and responses, but we do use that data internally to tailor education to cover areas in need.

For example, when we started to see denials regarding clinical validation, we began to focus on our policy and procedures as well as provider education. We do share publicly reported data with providers during group education. We use it as part of the “why should I care” conversation in particular.