If you think your hospital has “done” clinical documentation improvement (CDI), it may be time to think again. Improving your clinical documentation culture is not a one-time event – it’s an ongoing and evolving strategy that requires dedicated support and organisational commitment.
Thinking differently – the first step towards change
Improving your clinical documentation culture isn’t just a checklist-type process. To achieve long-lasting organisational change, you will need to encourage multiple stakeholders – from clinicians to clinical coders – to think differently and change the way they have been working for decades.
Many hospital documentation processes were established years ago, and behaviours based on these processes are now deeply ingrained. In hospitals around Australia, it’s common to find clinical documentation cultures that:
To change these cultures and improve your documentation processes you need an ongoing strategy, not a one-time event.
Looking back, some of the most successful hospital programs of our time – antimicrobial stewardship, falls prevention, pressure injury prevention – took years for hospitals to adopt.
Event-style initiatives may achieve a positive short-term result, but they rarely continue long-term in hospitals. That’s because CDI is, at its core, behavioural change, and instilling behavioural change within an organisation takes time, dedication, and commitment.
Embracing behavioural change can help you improve your clinical documentation culture
Successfully implementing a CDI program requires an evidence-based approach to behavioural change.
To encourage hospital staff to modify their way of working and adopt new processes, it’s important to consider the stages that make up the complex behavioural change processes that people undergo when changing deep-seated behaviours – from being unaware and contemplating change, to preparing, trying and maintaining for years to come.
Importantly, behavioural change – just like CDI – is a journey. You can’t change a behaviour overnight. Outdated documentation cultures can only be changed through organisational commitment and ongoing support.
Want to learn more about how we can support you on your CDI journey? Contact us today.
We invite you to share your ideas, experiences, and achievements in CDI by submitting content to the CDIA Community! Contact community@cdia.com.au to learn more.