Building Resilience in CDI Programs: 2024 HIMAA National Conference Workshop

This document compiles the key insights shared during this workshop, facilitated by Mike Kertes and Dr. Danielle Corish at the HIMAA National Conference 2024. Designed for health information management professionals, including CDI Specialists, Health Information Managers, Clinical Coders, Auditors, and Quality Improvement Officers, this workshop aimed to address the major risks impacting the success and sustainability of Clinical Documentation Improvement (CDI) programs. Participants explored critical topics such as clinical staff engagement, executive support, the appointment and training of Clinical Documentation Specialists, reporting strategies and the relationship between HIMs and CDI teams. This document serves as a valuable resource, summarising the practical strategies discussed to mitigate these risks and ensure the ongoing success of CDI initiatives.

Section 1: The Major Risks to CDI Programs:

During this workshop, participants identified key risks that can impact the success of Clinical Documentation Improvement (CDI) programs. These insights are valuable, in order to identify and address these challenges and ensure effectiveness of CDI initiatives.

The risks are displayed in descending order, from the most common to the least common risks identified:

1. Clinician engagement [13]
2. Budget and/or lack of resources [9]
3. Having an appropriate person for the CDS role [8]
4. Lack of executive support [8]
5. Poor reporting and/or monitoring measures [7]
6. CDI scope creep [6]
7. Lack of education and/or training in CDI [6]
8. Communication breakdown between HIM, coders and the CDS(s) [6]
9. Emphasis on the fiscal impact and not patient safety/data quality [4]
10. Lack of understanding and/or awareness of CDI [4]
11. Lack of structure or strategies within the program (e.g. having measurable goals and objectives) [5]
12. General lack of support for CDI [3]
13. Inconsistencies between different states and hospitals [1]
14. Lack of escalation processes [1]
15. Private funding models [1]
16. CDI fatigue [1]
17. Lack of an understanding of clinical coding [1]

HIMAA conference members also identified some more specific challenges with clinician engagement:

• Rapid rotation of junior doctors in the public healthcare system, leading to inconsistent documentation and knowledge gaps.
• Inconsistent documentation by junior doctors, impacting the quality and accuracy of clinical records.
• Lack of consistency in documentation standards from senior clinicians, making it difficult to maintain uniformity.
• Limited doctor-to-doctor education, with insufficient opportunities for peer learning and knowledge transfer.
• Illegible handwriting and time pressures on junior doctors and VMOs, contributing to poor documentation quality.
• Time constraints, leaving little opportunity for doctors to engage fully in CDI processes.
• Challenges in identifying a "physician champion" who can advocate for and support CDI initiatives.
• Limited opportunities for meaningful engagement, with few structured avenues for doctors to participate in CDI-related activities.

Addressing these risks is crucial to optimise performance of CDI programs. By tackling these challenges, organisations can improve documentation accuracy, enhance patient care outcomes, data integrity and hospital revenue. Some of the risk mitigation strategies developed by workshop attendees are outlined in the next section.

Section 2: Risk Mitigation Strategies:

Next, we will look at the strategies developed by HIMAA workshop attendees to mitigate certain risks in CDI programs.

Lack of Executive Buy-In and Engagement

• Define and communicate the program's scope and objectives.
• Clearly communicate the "why" behind the program and its importance.
• Provide clear and transparent reporting of results.
• Offer regular, ongoing feedback to executives on progress.
• Tailor feedback to executives by highlighting key metrics, such as revenue impact and other relevant outcomes.

Poor Quality Reporting and Strategies

• Establish and adhere to a definitive methodology.
• Ensure consistency across all processes.
• Involve reliable and qualified staff.
• Ensure a high quality of information.
• Perform live reviews of medical records (concurrent CDI).
• Provide timely feedback to all stakeholders.
• Clearly define and communicate risks.
• Involve IT and data analytics teams (e.g. dashboards and/or integrated systems).

Lack of Symbiotic Relationship Between HIM and CDI Staff

• Foster communication and ensure shared goals.
• Adopt a multidisciplinary approach by attending bed meetings, coding meetings, and case-mix meetings.
• Ensure a thorough understanding of CDI, especially regarding addressing gaps in documentation.

Insufficient or Inadequate Training in CDI for Clinical Documentation Specialists and Other Stakeholders

• Invest in staff education in CDI.
• Consider outsourcing CDI education.
• Build rapport and collaboration between stakeholders.
• Develop tailored strategies for different teams.
• Implement active strategies to improve team collaboration (e.g. "ground rules").
• Ensure a good line of communication between coders and HIM staff.
• Provide ongoing CDI education.
• Look for executive support.
• Implement robust reporting measures.

• Standardise reporting strategies for CDSs and coding teams.

Absence of a Formal CDS Role

• Consider structured templates and forms to guide documentation.
• Offer clinician education on CDI.
• Improve education and orientation to CDI, considering a more tailored approach in different specific specialties.
• Ensure clinicians understand the link between CDI and patient safety.
• Engage senior clinicians in CDI processes.
• Develop a structured program with scheduled meetings and feedback.
• Raise executive awareness about the importance of the CDS role.
• Position CDI staff as being "on their side" to increase engagement.
• Benchmark CDI programs with those of other healthcare institutions.
• Conduct regular clinical documentation audits.

Ineffective CDS Appointment (Wrong Person)

• Focus on targeted recruitment and pre-qualification in CDI roles.
• Ensure appropriate training for newly appointed CDSs.
• Offer new opportunities for engagement to maximise effectiveness.
• Ensure standardised job descriptions, qualifications, and skill requirements for CDS positions.

Lack of Support for the CDS

• Raise facility-wide awareness of CDI.
• Educate teams and clinicians in CDI, including staff turnover periods.
• Promote the value of CDI programs.
• Emphasise benefits such as reduced workload and improved time management for clinicians.
• Accumulate evidence showing quality and revenue improvement linked to CDI.
• Ensure executive understanding and engagement with the CDI process.
• Identify additional clinicians who can assist in cases of poor clinician engagement.
• Increase CDS visibility and presence within the organisation.
• Hire CDS staff with a clinical background to improve respect and understanding.
• Foster close collaboration between CDSs, coders, and HIM staff.
• Consider creative incentives (e.g. chocolate!).
• Conduct regular reviews (e.g. weekly/monthly) to assess and adjust interventions.

CDI Scope Creep

• Develop and maintain a well-defined CDI plan.
• Raise executive awareness around scope creep and ensure commitment to managing it.
• Clearly define roles and expectations for CDI staff.
• Consider the size of the hospital and the potential service impacts.

Ineffective Communication and Rapport with Staff to Foster a Supportive CDI Environment

• Ensure alignment on shared objectives.
• Define measurable outcomes for CDI performance.
• Offer CDI-specific training programs and educational opportunities.
• Identify and engage CDI champions within the organisation.
• Provide ongoing education and engagement for all staff.
• Engage with the multidisciplinary team for broader support.
• Communicate the CDI framework clearly to executives to ensure understanding of expected outcomes.
• Clearly define the CDI role and communicate it to the team.
• Develop a comprehensive "onboarding" pack that clearly explains roles, responsibilities, and expectations across all relationships.

Lack of Opportunity to Develop a CDI Role or Program

• Continue to foster collaboration between CDI, coding teams, and clinicians.
• Invest in coder education.

Lack of Direction Within a CDI Program

• Increase awareness of the program's benefits.
• Educate staff on the "why" behind CDI and its potential benefits.
• Provide ongoing education (e.g. at M&M meetings or 1:1 discussions).
• Consider implementing clear guidelines for CDI processes.
• Hire the right person to lead the CDI program.
• Establish strong reporting measures to track progress.
• Hold regular meetings for feedback and continuous improvement.
• Encourage collaboration and communication between all stakeholders.
• Focus on improving data quality, rather than just financial incentives.
• Consider co-locating CDS and coding staff offices for improved communication.
• Outline clear benefits and incentives, such as new equipment or resources, to increase CDI engagement.

To address the various challenges in clinical documentation improvement, organisations must focus on clear communication, targeted training, and ongoing support for, coders, HIMs, CDS staff and clinicians. Key strategies include defining the program’s scope, ensuring executive buy-in, fostering multidisciplinary collaboration, and providing consistent and transparent feedback. We now turn our attention to opportunities for increasing clinician engagement, which can further enhance the success of CDI programs and their impact on quality, data integrity and financial outcomes.

Section 3: Focused Discussion on Clinician Engagement

Finally, we will take a look at strategies developed by HIMAA workshop attendees to address specific challenges in clinician engagement.

Scenario: A group of experienced clinicians in a large hospital are resisting new CDI protocols, citing "no time" to adjust their documentation habits.

Discussion Points:

• Emphasise the broader benefits, including patient safety, quality of care, and accurate clinical documentation.
• Explain how improved documentation supports appropriate reimbursement and the allocation of resources.
• Highlight executive and senior clinician support for the changes, demonstrating alignment with organisational goals.
• Consider involving external providers for peer-to-peer education, which can offer credibility and foster acceptance.
• Encourage collaboration among clinicians, with more senior staff sharing their learning experiences to help guide others.
  

2. Lack of Feedback Mechanisms: "I’ve changed my documentation, but I’ve never heard anything back. It’s hard to know if I’m doing it right!"

Scenario: Clinicians receive little to no feedback on their documentation efforts, leading to disengagement and recurring errors.

Discussion Points:

• Provide regular, constructive feedback on documentation changes and their impact on patient outcomes.
• Hold regular meetings to build rapport and ensure clinicians feel supported.
• Close the feedback loop: when improvements are made, make sure clinicians know the outcomes.
• Consider feedback channels like emails or unit meetings to ensure consistency and visibility.
• Introduce CDI Champions to communicate ongoing improvements and success stories.
  

3. Competing Priorities: "I need to prioritise my patients over paperwork. Documentation doesn’t save lives, right?"

Scenario: A busy surgical ward faces documentation challenges, with clinicians feeling that patient care should take precedence over documentation tasks.
Discussion Points:

• Educate clinicians on how good documentation enhances clinical communication and patient safety.
• Discuss the legal implications of documentation and its role in minimising risk.
• Show the time-saving benefits of thorough documentation (e.g., fewer retrospective queries) and how it leads to more accurate coding.
• Share examples of poor documentation leading to incidents or regulatory issues, emphasising its broader impact on patient care and hospital operations.

4. Inadequate Education: "I’m confused about these CDI protocols. No one explained them clearly, and I feel lost."

Scenario: Clinicians poorly understood newly introduced CDI programs due to insufficient education, resulting in minimal changes and persistent documentation issues.
Discussion Points:

• Provide training on both coding and the financial implications of clinical documentation improvement.
• Offer orientation sessions for new clinicians, and regularly update all staff through ongoing education.
• Use a mix of 1:1 training and group sessions, with follow-up to ensure understanding.
• Appoint clinician champions within each department to lead by example and provide peer support.
• Consider online training courses to reinforce key concepts and offer flexibility.

5. Negative Perception of CDI: "The CDI team just seems to be looking for mistakes. I don’t feel supported."

Scenario: Clinicians view the CDI team as "policing" rather than collaborating, which creates resistance to engagement.

Discussion Points:

• Educate clinicians on the purpose of CDI: to support accurate documentation, improve patient safety, and reflect clinical complexity.
• Emphasise that CDI’s role is not punitive, but supportive, aimed at improving patient outcomes.
• Highlight that CDI teams are there to help document the clinical truth, not to criticise.

6. Fragmented Communication: "I thought we were supposed to be on the same page, but I keep getting conflicting instructions from different people."

Scenario: Miscommunication between CDI specialists, coders, HIM professionals, and clinical staff leads to frustration and inconsistent goals.
Discussion Points:

• Ensure that messages from all departments are consistent and aligned.
• Use a top-down approach to ensure senior consultants and leaders provide clear, unified messages about CDI priorities.
• Hold regular meetings to improve communication and alignment across disciplines.

7. Insufficient Resources: "With so few staff members, it’s impossible to keep up with documentation. I feel like I’m drowning."

Scenario: A small rural hospital lacks adequate staffing and resources for a CDI program, leading to clinician burnout and disengagement.
Discussion Points:

• Address resource limitations and advocate for additional staffing to support the CDI program.
• Ensure that clinicians' well-being is prioritised and recognise the strain that inadequate resources can cause.
• Work with leadership to prioritise sustainable CDI efforts that reduce clinician burnout and improve documentation accuracy.

8. Cultural Barriers: "It’s the other surgical team’s way of documenting that’s causing the documentation issues, and I don’t want my complication rate to increase!"

Scenario: Differing attitudes toward documentation standards among various departments hinder engagement in CDI initiatives.

Discussion Points:

• Reinforce the importance of standardised documentation to maintain accuracy across departments.
• Create a culture where clinically accurate documentation is seen as part of the patient care journey, not an administrative burden.
• Identify specific departmental needs and tailor education to show "what’s in it for them" to make it relevant.
• Conduct pre- and post-audits to assess the impact of education on departmental documentation practices.

9. Lack of Clinical Relevance: "I just want to focus on taking care of my patients, not wasting time on more documentation."

Scenario: Clinicians question the relevance of CDI efforts, perceiving them as disconnected from their day-to-day practices.
Discussion Points:

• Explain how good documentation is directly tied to better patient safety and accurate care delivery.
• Link clinical documentation to tangible benefits like increased resources, better hospital reimbursement, and improved patient outcomes.
• Ensure clinical relevance in CDI programs by involving clinicians in the decision-making process.
• Focus on the clinical truth and how accurate documentation supports their care plans.

10. Burnout and Overwork: "I don’t have time for this, I’m already too busy!"

Scenario: Elevated levels of clinician burnout led to disengagement from CDI initiatives, with documentation seen as an additional burden.
Discussion Points:

• Start by collaborating with clinicians who are engaged and interested in learning about CDI to build momentum.
• Present data showing how CDI improves patient safety, reduces risk mitigation, and saves time by reducing retrospective queries.
• Emphasise that CDI isn’t asking for more documentation, just accurate reflection of the clinical truth.
• Offer flexible scheduling for CDI education and meetings, working around clinicians' busy schedules.

11. Request for Valuable Codes: "Why don’t you just give us a list of the codes with big revenue?"

Scenario: Clinicians ask for a list of high-revenue codes to streamline documentation and improve accuracy, but the CDI team is reluctant to provide this for fear it may prioritise financial concerns over clinical accuracy.
Discussion Points:

• Clarify that the goal of CDI is not just to improve revenue, but to enhance patient safety and the quality of clinical data.
• Discuss how accurate coding contributes to the overall healthcare system, including appropriate reimbursement and better care coordination.
• Keep conversations light and open about the benefits of accurate documentation.
• Consider increasing the visibility of the CDS through dedicated spaces or digital platforms to make the process more accessible.

12. "Why can’t the coders just code from my plans – it’s obvious!"

Scenario: Some clinicians are frustrated, believing their treatment plans are clear enough for coders to understand without additional context.
Discussion Points:

• Educate on the importance of linking diagnoses and treatment plans to ensure accurate coding.
• Emphasise that CDI focuses on documenting the clinical truth, not just filling out forms.
• Discuss the need for thorough discharge summaries to capture the full clinical picture.

13. The Junior Doctor’s Dilemma: "My consultant never explains his thought processes, so I never know what the diagnosis is, and I’m too intimidated to ask."

Scenario: Junior doctors are unsure about patient diagnoses due to a lack of communication from their consultants, leading to confusion and errors in documentation.
Discussion Points:

• Encourage open communication between junior and senior doctors to foster learning and clarity.
• Provide education and training on CDI to ensure junior doctors understand the importance of clear documentation.
• Collaborate with senior doctors to share their thought processes and encourage a supportive environment for questions and learning.

To improve clinical documentation, it's crucial to foster collaboration between clinicians and the CDI team, ensuring clear communication and mutual support. Ongoing education and feedback loops are essential to keep clinicians engaged and to reinforce the value of accurate documentation for patient safety and hospital performance. By addressing cultural barriers, competing priorities, and resource limitations, hospitals can create a sustainable, effective CDI program.

The workshop underscored the importance of a collaborative approach to CDI, involving ongoing education, clear communication and continuous feedback. By addressing clinician concerns, aligning CDI goals with organisational objectives and fostering executive support, healthcare organisations can build resilient and sustainable CDI programs that improve documentation accuracy, patient care, and financial outcomes.