Improving CDI: Taking Your Program from Good to GREAT

2. Improving CDI: Taking Your Program from Good to GREAT Fran Jurcak, RN, MSN, CCDS Director, Clinical Documentation Improvement Huron Consulting Group Chicago, IL

3. Evaluating your CDI Program • Scope of practice • Appropriateness of staffing • Administrative oversight • Tracking tools • Physician engagement • Opportunities • Discharged records • Clinical examples • Future Plans

4. Assess Program Scope

5. Program Assessment • Program purposes • Payers being reviewed • Additional diagnoses • CC/MCC capture • Present on Admission • Signs and symptom diagnoses • Completeness of record • Principal diagnosis • Medical necessity • Core Measures

6. Chart Review Priority ACDIS: 2010 CDI Program Benchmarking Survey

7. Best Practice • Dedicated Role • Accuracy of clinical documentation • Principal Diagnosis • Severity of Illness • Risk of Mortality • Review of every record • Physician education • Planning for ICD-10 Good to Great!

8. Impacting Documentation

9. Organizational Structure ACDIS: 2010 CDI Program Benchmarking Survey

10. Balancing Program Goals Finance Quality • Improve reimbursement • Reduce risk of denials • RAC calls this DRG Validation • Complete and accurate documentation of quality measures • RAC calls this Clinical Validation

11. Creating the Balance • Accurate documentation that supports the conditions being monitored and treated throughout the course of the patient stay will result in appropriate severity of illness and compliant reimbursement. Quality Finance

12. Staffing • Number of Reviews • 10-15 Initial reviews/day • 15-20 Follow up reviews/day • Weekend Coverage • Admit and discharge Documentation opportunity does not just occur Monday through Friday, 9-5! Good to Great!

13. Record Review • Goal • 100% of identified payers • Subtract discharge numbers from clinical areas not covered by CDI Specialists • Typical Benchmark • >80% • Retrospective review possibilities • Post discharge • Records of deceased Good to Great!

14. Productivity Property of F. Jurcak, 2010

15. Query Impact ACDIS 2010 Physician Query Benchmarking Survey,

16. Process • Type of Query • Principal Diagnosis • Present on Admission • Procedure • CC/MCC • Query Indicators • Inclusion of rationale for the query • Should include: • Risk factors, signs/symptoms, treatment

17. Process • Method of Query Communication • Concurrent vs retrospective • Paper vs electronic • Templates • Provide consistency • Enhances physician participation

18. Template Example ACDIS Resource Library: Provided by Susan A. Klein, BSN, RN, C-CDI, Saint Peter's University Hospital in Monroe Township, NJ

19. Template Example ACDIS Resource Library: Courtesy of Sandy Beatty, Clinical Documentation Specialist for Columbus Regional Hospital

20. Process • Query Issues • Location in record • Ease of physician recognition • Permanency • Permanent part of record…or not • State QIO and RAC • Leading vs nonleading • Clinical indicators

21. Query Quality • Regular review of query forms • Content • Structure • Quarterly audit of CDI Specialist queries • Peer to peer review • Quarterly updates/education for CDI staff Good to Great!

22. Query Metrics Property of F. Jurcak, 2010

23. Process • Follow up • Frequency • 12-20 Follow up reviews/day • Rationale • Previous query answer • New query • Other measures • Physician Education

24. Program Success • Tracking Data • Method of tracking • Data to Track • Review Rate • Query Rate • Physician Response Rate • Physician Acceptance Rate • CMI changes • Tracking Quality • Query forms • CDI Specialist queries

25. Physician Engagement

26. Process • Physician Response • Identifies • Physician acceptance of CDI program • Quality of process • Goal 100% • Medical Staff by-laws • Physician Report cards Good to Great! Good to Great!

27. Process Property of F. Jurcak, 2010

28. Physician Support

29. Physician Communication • How • Face to face • Service Line meetings • Permanent agenda item • 10-15 minute update • Metrics over time • Medical Staff meetings • Permanent agenda item Good to Great!

30. Physician Education • Documentation Concerns • Content • Clarity • Consistency • Appropriateness • Documents • History and Physical • Progress Notes • Discharge Summary

31. Physician Report Cards • Include • Number of Discharges • Length of Stay • CMI • Response Rate • Track metrics monthly • Physician Advisor Involvement • One on one with physicians Good to Great!

32. Support • Physician Advisor • Nearly 50% of CDI programs have an active physician advisor • Role includes: • Follow up with physicians regarding queries • Peer to peer education • Clinical resource to CDI team • Write appeal letters Good to Great!

33. Documentation Improvement Opportunities

34. Process • Retrospective Follow through • Unanswered Queries • Prior to coding/billing • CDI Specialist after discharge • After coding/billing • Continued as coding query ACDIS 2010 Physician Query Benchmarking Survey,

35. Discharged Records Good to Great!

36. APR-DRG • All Patient Refined Diagnoses • Capturing all conditions being monitored and/or treated • Severity of Illness • Extent of physiologic dysfunction • Risk of Mortality • Likelihood of dying

37. Example • 86 yo female with history of COPD, CHF and DM is admitted with shortness of breath and pneumonia. Respiratory rate is 34, pulse oxygenation is 78% on RA. Patient is started on IV antibiotic, O2 via venti-mask and transferred to telemetry. MS-DRG = 195 APR-DRG = 139 SOI = 2 - moderate ROM = 2 - moderate

38. Specificity • With greater specificity of the stated diagnoses MS-DRG 194 APR-DRG 139 SOI = 3 - major ROM = 2 - moderate

39. Documentation Improvement • With documentation of Acute Respiratory Failure MS-DRG 193 APR-DRG 139 SOI = 3 – major ROM = 3 - major

40. After 24 hours of treatment with IV antibiotics, the patient’s creatinine increases and the physician also documents acute renal failure MS-DRG 193 APR-DRG 139 SOI = 4 – extreme ROM = 4 - extreme

41. Capturing the Total Picture • APR-DRG’s attempt to capture: • Type of patient being treated • Costs incurred in the treatment • Expected services • Anticipated outcomes • Goal of CDI Program: • Ensure that all conditions being monitored and treated are documented clearly and consistently.

42. Capturing the Diagnoses • 67 yo male with history severe COPD and pulmonary HTN presents with shortness of breath, noted neck vein distention and mildly elevated BNP. • Patient is treated with oxygen, nebulizer treatments, IV steroids and IV lasix • Physician documents exacerbation of COPD, pulmonary HTN and CHF

43. Cor Pulmonale • Defined as an alteration in the structure and function of the right ventricle caused by a primary disorder of the respiratory system • Pulmonary Hypertension is the common link between lung dysfunction and the heart in cor pulmonale • Although cor pulmonale commonly has a chronic and slowly progressive course, acute onset or worsening cor pulmonale with life-threatening complications can occur

44. Pathophysiology • Pulmonary vasoconstriction due to alveolar hypoxia or blood acidemia – This can result in pulmonary hypertension and if the hypertension is severe enough, it causes cor pulmonale • Anatomic compromise of the pulmonary vascular bed secondary to parenchymal or alveolar lung disorders • Chronic obstructive pulmonary disorder is the most common cause of cor pulmonale

45. Prevalence • Cor pulmonale is estimated to account for 6-7% of all types of adult heart disease in the United States • Chronic COPD due to chronic bronchitis or emphysema is the causative factor in more than 50% of cases • Accounts for 10-30% of decompensated heart failure–related admissions in the United States Han MK, McLaughlin VV, Criner GJ, Martinez FJ. Pulmonary diseases and the heart. Circulation. Dec 18 2007;116(25):2992-3005

46. Signs and Symptoms • General • fatigue, tachypnea, exertional dyspnea, and cough • Physical findings • Wheezes, crackles, right ventricular hypertrophy, labored breathing, increase in chest diameter, cyanosis, hemoptysis, distended neck veins

47. Diagnostics

48. Treatment • Care of underlying respiratory condition • Oxygen • Diuretics • Vasodilators • Bronchodilators • Steroids

49. Accurate Documentation • Clinical picture of the patient • Resources being consumed As principal diagnosis Acute Cor Pulmonale groups to DRG 314-316 Other Circulatory System Diagnoses What was monitored and treated?

50. Future Plans