During a heated debate among members of a CDI committee about what the targeted physician response rate should be, one of the more reserved members of the newly formed group (an IT analyst) asked the question, "What would happen if the physicians decided their own response rate?" It was an academic medical center. There were 12 people on this committee. Half of the members did not hear the question and the other half pretended not to hear it. But then, the CFO, who was in attendance that day asked the IT analyst to repeat his question. This time, everyone listened.
Ruthann's CDI Blog
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Ruthann’s CDI Blog…..informal writings about clinical documentation in patient records…everything here is tested through my work and research on CDI….nothing here is “official”. I hope you will find it to be a useful, perhaps even supplemental tool for your work. And, on a really bad day, something to help uplift your spirits and gain some perspective! |
Heart-to-Heart on the Verbal Query
When I was on the task force that created AHIMA's white paper entitled, Managing an Effective Query Process, the issue of verbal queries created much heated debate. In the end, the white paper said only the following about verbal queries: "Verbal queries have become more common as a component of the concurrent query process. The desired result of a verbal query is documentation by the provider that supports the coding of a condition, diagnosis, or procedure. Therefore entities should develop specific policies to clearly address this practice and avoid potential compliance risks." Recently, I revisited the issue of verbal queries with a hospital and it brought back the memories of those heated debates. Time Management for Physicians
When researching the Time Management for Physicians handbook, I came across some physician stories about how they managed time that was quite eye-opening. Each of these stories highlights just how stressed and unbalanced a physician’s professional life can be. See what you think….
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Another winner
Another Biggest CDI Challenge winner, Stacey Forgensi, is announced. You can read Stacey's complete story on the home page of the CD Matters website. I just wanted to re-emphasize here in the blog why I chose Stacey's story. Stacey's is a story of true challenge in employing a multi-tiered strategy to obtain accountability from the physicians for their clinical documentation practices. Her's is a bittersweet, yet familiar ending, with surgeons choosing to abstain and family medicine physicians all in favor. Here are some of the many strategies Stacey used to obtain accountability, taken directly from her story: New CDI Resources Available Free to CD Matters Subscribers
No matter how you slice it, clinical documentation improvement is about change. And, my research has shown that physicians involved in a new CDI program are most concerned about whether they will have "enough time to document properly." Ironically, after the training sessions we conducted with physicians in our studies, 78 percent felt as though they were actually able to document more efficiently because they felt more confident about what they were documenting. None the less, time management is an issue for physicians. Period. Therefore one of the resources we've compiled is a Time Management Guide for Physicians. While the guide is useful for CDI programs, physicians can benefit from the content at anytime. We pulled research together that looked at what worked best for physicians as well as non-physicians and melded it into a simple 30-page document that you can share with your medical staff. The other resource Change Management for Clinical Documentation describes the 8 essential activities for successful change management and can be used in either initial implementation of a CDI program or to improve an existing one. Will be writing more about these two resources and Time and Change management in the weeks to come. In the meantime, enjoy! What a difference a word makes
This week marks the beginning of the announcements of the winners of the Biggest CDI Challenge. Our first winner is Salath Hard from Multicare Health Systems. Salath's story was chosen because she addressed two important issues quite eloquently. The first was a career change from an ED nurse to a CDI professional. Her story, which you can read in full on the home page of the website, details her feelings about the change as well as why she made the change - I think many of Salath's peers will benefit from reading about how she managed the change. Second, Salath also addressed the issue of why we want to improve documentation. She is quite persuasitve in her description of the government changes, severity issues, and patient benefits of improved CDI. I hope you will take the time to read What a Difference a Word Makes by Salath Hard.
We're most comfortable with the familiar
Many years ago, I had the task of hiring computer programmers to create some healthcare software. While I knew alot about the subject matter and the content for the programs, I knew nothing about programming or the people who did this for a living. And, I realized quickly, that you don't conduct an interview with a programmer in the same way that you do for a marketing assistant or an HR manager. Money and the meaning of clinical documentation
A few physicians remained behind after the conclusion of a CDI training session at an academic medical center. There were some general comments about how much the hospital might benefit economically from improved clinical documentation. But then one of the organization's physician leaders, an orthopedic surgeon, offered the following example of how he makes decisions about which patients need a joint replacement. He said, "It's simple, if my kid's tuition is due, the patient needs a replacement. If I'm leaving on a tropical vacation, then they can get by with conservative treatment." |
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