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Gauging the Effectiveness of Your Clinical Documentation Improvement Program
How do you gauge the effectiveness of any clinical documentation improvement program? This is a highly opinionated question that often surfaces and is certainly worthy of discussion. The answers to this question must take into several broad based considerations including type of clinical documentation improvement model implemented, detailed structure of the program, how long the program has been up and running, overall goals and objectives of the program, and whether the program was implemented with outside consultants or implemented through a “home grown” approach. Let’s take a look at the factors to consider in measuring success of your clinical documentation improvement program.
Clinical documentation improvement by definition cannot and will not be successful operating within a vacuum. With this in mind, most CDIP are initially rolled out by way of introduction to the medical staff and other ancillary care providers through one or two organized presentations with a consultant or in-house speaker highlighting the importance of clinical documentation to the practice of medicine. The objectives in these presentations are to solicit buy-in and support of the clinical documentation improvement program in the hopes of peaking the physician’s interest and participation in the program. Obviously without achieved buy-in from the physicians, the program is likely destined for failure or less than planned and expected success.
As a CDIP program is developed and plans made for rollout and implementation of the CDI program, the key decision of whether to utilize case managers; physicians, nurses, coders or a combination as clinical documentation specialists must be made. The decision rests with the culture of the medical staff, size of the hospital and number of admissions, talent pool to pull from and goals and objectives of the program.
The structure of the CDIP must be factored into any decision of planning, developing, and implementing of the program. The following considerations are relevant to the proposed structure of an effective CDIP. Will the program initially be staffed to limit review to Medicare only records, Medicare/Medicaid records, Medicare and all payers, all payers that reimburse on a DRG system, or all third party payers? How many clinical documentation improvement specialists will the program begin with, will there be seven day a week coverage or just Monday through Friday coverage, what software will I use to track and trend results of the CDIP initiative, what criteria for success of the program will be established, and what dashboards will I use for administrative reporting. Other considerations include establishing the initial, mid-term, and long-term goals and objectives of the program that include reliable and quantifiable measurement of achievement and success, and whether the hospital will start with development and implementation of a home grown CDIP, contract with the services of a consultant with a proven track record of rolling out effective clinical documentation improvement programs, or employ a hybrid model using consultants mainly for guidance and direction.
Now for judging and measuring the effectiveness of your clinical documentation improvement program
. There are numerous ways to measure the direct impact and success of a clinical documentation improvement programs. The following lists represents commonly recognized measures of success but in no way can be considered to be conclusive:
- Number of records reviewed by CDIS each day
- How many times the CDIS reviews each record before discharge
- Time that elapses before the CDIS performs an initial chart review
- Number of queries left by the CDIS in the categories of clarification of principal diagnosis, secondary diagnosis (CC or MCC) or improved severity only
- Query response rate with agree, disagree, no response
- Number of queries that changed the MS-DRG to a higher weighted DRG as well as lower weighted MS-DRG
- The number of cases initially queried concurrently that were not answered and required retrospective follow-up with a written or verbal query to obtain clinical documentation
- Increase in case mix as a whole as well as separate reporting of medical and surgical MS-DRGs
- Quality of clinical documentation in the medical record in support of medical necessity for admission as measured by the number of cases reported monthly where condition code 44 was used
- Calculation of monthly CC and MCC capture rate aggregated by all cases, surgical cases and medical cases
- Number and percentage of cases reported monthly where coder final MS-DRG assignment agrees with final CDIS MS-DRG assigned.
- Number of cases denied by payer reported monthly for medical necessity or involving resequencing of clinical diagnoses/deletion of secondary condition resulting in assignment of lower weighted MS-DRG assignment.
The reality of measuring overall success and effectiveness of a clinical documentation improvement program is that the focus of measurement should not be strictly on financial reimbursement and calculation of the CC/MCC capture rate. The outcome of clinical documentation improvement that focuses upon affecting positive change in behavior modification of physician practice patterns of clinical documentation will achieve an added byproduct of enhanced reimbursement reflective of captured patient acuity and intensity of service that more closely approximates resource consumption. The focus of clinical documentation should be on physician education on the merits and importance of complete, accurate, specific, and detailed documentation that supports their clinical judgment and acumen, medical decision making and treatment decisions, patient risk of morbidity and mortality and potential for readmissions, all necessary components of establishment of medical necessity for physician’s evaluation and management assignment. Directing efforts at only capturing CCs/MCCs in the name of increased reimbursement disengages physicians in participation in any efforts at clinical documentation improvement efforts, regardless of how the program is crafted.
By focusing upon efforts at true physician education, the number of queries that must be left over time to clarify and solidify inconsistencies and incompleteness of clinical documentation should drop overtime as physicians take note of the importance of and techniques in proper and effective clinical documentation reflective of their medical management and complexity patient care. The number of denials for medical necessity for inpatient admission should decrease over time as physicians understand and begin to document in their History and Physicals and progress notes the true patient’s severity of signs and symptoms upon presentation to the Emergency Room, descriptive picture of the patient’s history of present illness, encompassing clinical impression and assessment of the patient in both the H & P as well as progress notes, clear picture of patient response to treatment, and detailed account of patient admissions through dictation of a complete discharge summary that provides for a accurate synopsis of patient admission from presentation to the Emergency Room through decision to admit the hospital, treatment and progress in the hospital through decision to discharge the patient from a clinical stability standpoint.
Gauging the effectiveness of a clinical documentation program by necessity entails a holistic approach to planning, developing and implementing a program that incorporates the goals and objectives of physician education on principles of best practices in clinical documentation and promotion of clinical documentation to the physician’s business of the practice of medicine. To this end, the perpetual treadmill of constantly leaving queries for clarification of the same clinical condition is avoided as physicians learn to documentation with the level of detail and specificity necessary to accurately depict and capture and report patient acuity and establish medical necessity for services rendered from a physcian and hospital perspective. More time can be devoted by the clinical documentation improvement staff in working with physicians as well as nurses in improving clinical documentation that bests clearly signifies the clinical confirmation of documented diagnoses using an interdisciplinary approach. Effectiveness of clinical documentation improvement programs is predicated upon implementation of processes that promote the teaching and recognizing of the concept of reasonable and medically necessary and supporting documentation as key elements of medical record documentation. The interdisciplinary team documentation of assessment, intervention, and outcomes provides a picture of the patient’s clinical condition and response to treatment. Each component is useful in determining reasonable and medically necessary services provided and billed to the third party payer for reimbursement.
If you already have an established clinical documentation improvement program in place, now is the ideal time to take a hard look at the success of the program and determine if the program is meeting and achieving its potential in light of the added value of complete, accurate, and detailed clinical documentation beyond financial reimbursement. There is real value in clinical documentation including reduction and mitigation of financial exposure associated with the Recovery Audit Contractor’s efforts at identifying improper payments under the guise of medical necessity. If you do not have an existing clinical documentation improvement program, now is the time to plan, develop, and implement a program that incorporates principles of clinical documentation that incorporates a “holistic” approach with engagement of the interdisciplinary team.