Clinical Documentation Improvement (CDI) programs rely on many factors for not only successful outcomes, but also for sustainability. These factors stem from a broad range of decisions including the appointment of the CDS(s), program vision and values, HIS and coding workflows, data collection and reporting, and an education strategy to engage clinicians. All of these decisions rely on the engagement and support of the hospital's executive leadership. In this article, we unlock the fundamentals of successful CDI through effective hospital executive engagement.
The foundation of a CDI program begins with a proactive partnership between hospital executives and the CDI team. Executives must lead by example, demonstrating an innovative approach to collaboration, which involves not only understanding the intricate processes of CDI but also actively engaging with the CDI team. Trustworthy leadership ensures that the mission of the CDI program to drive sustained behavioural change in documentation aligns with the hospital's overall culture, and reinforces the hospital's commitment to quality patient care, accurate data, and revenue optimisation reflective of the hospital's complexity.
It need not be excessive, but the hospital's executive CDI sponsor should regularly convene with the CDI team to review progress, address challenges, and celebrate successes. An authentic engagement will help to build a cohesive team dedicated to the continuous improvement of clinical documentation.
Hospital executives play a pivotal role in setting a culture that promotes excellent clinical documentation. Hospital executives must support and promote the principles of behavioural change and continuous improvement, instilling a sense of professional responsibility in each clinician's documentation practice.
Moreover, executives have the responsibility to ensure that the tools for improvement are readily available to the CDI team. By endorsing ongoing education and training, they affirm their commitment to upholding the highest standards in patient safety documentation. This not only supports the immediate goals of the CDI program but also contributes to an overarching ethos of excellence within the organisation.
An effective CDI program requires the appropriate resources to thrive. All too often, a hospital leader will appoint a single CDS resource into a large hospital and think they have "done CDI."
But the appointment of the CDS is just one of many important factors to the success of a CDI program. Hospital executives must be innovative in identifying and allocating the necessary resources that will empower not only one CDS, but a CDI team. This includes investing in an appropriate number of CDSs to increase coverage and mitigate the risk of attrition, fit for purpose technology solutions (e.g. EMRs) with CDI capabilities that will improve the operational efficiency of the CDI team and demonstrate through key metrics the effectiveness of the CDI program.
Executives should engage in strategic planning to support CDI initiatives. With clinical documentation underpinning how hospitals are funded, demonstrating a significant return on investment ensures that that every dollar spent translates into not only increased revenue, but more importantly improved patient safety and better data quality. Supportive resource allocation demonstrates an authentic commitment to the organisation’s growth and the optimisation of its clinical documentation processes.
Hospital executives should be advocacy beacons for CDI through their regular clinician interactions. By actively promoting the importance of quality documentation and the purpose of their CDI team, they can inspire clinicians to embrace good CDI practices as part of their day to day. Executives should be visible and vocal champions, highlighting the direct benefits of CDI to patient safety, the integrity of their clinicians and hospital data, and the financial health of the hospital.
The promotion of CDI by executives though also involves recognising and addressing the specific challenges faced by clinicians, such as burnout and administration avoidance and fatigue. To make documentation improvement friction reducing by harnessing simple and effective ways to improve their documentation practices, executives can provide the necessary support and resources to overcome them.
To ensure the success of a CDI program, hospital executives must align its goals with the broader strategic objectives of the organisation. This requires a serious and thoughtful approach to integrating CDI into the fabric of the hospital's operations.
Engagement in strategic planning sessions, where CDI objectives are woven into the hospital’s mission and vision, can ensure that every level of the organisation understands and supports the program. By being professional and informative in their communications, executives can respect and harness the expertise of their teams to drive the organisation towards a future where CDI is not just a program, but a fundamental aspect of the hospital’s success.
Simply put, without good engagement from the hospital executive team, CDI programs will stagnate and eventually fail. The success of a CDI program relies on an executive team that understand the importance and impact of accurate and concise clinical documentation, the role and purpose of their CDI team, and most importantly their role in resourcing, supporting, and advocating for a culture of clinical documentation integrity.