The recent transition to ICD-10 underscores the paramount importance of clinical documentation improvement (CDI). Many providers are still struggling to use the new system of codes correctly, and even those that feel fluent with the system need a way to regularly audit, monitor, and improve performance. That raises the important question – what makes CDI successful, and how can providers make the most of their CDI initiatives?
There are many answers to that question, but ultimately the success or failure of any CDI initiative comes down to people. Without the right staff in place at both lower levels and in management positions there is no way for CDI to operate with the accuracy, authority, or granularity it requires over the long term.
Consider, for example, the process of CDI. Given the scope of the subject, the only way to proceed is in a systematic manor. With the right system in place, more instances of documentation failure will come to light and improvement initiatives will have a deeper impact. But it’s the CDI staff who develop these processes in the first place, and then monitor them for effectiveness and make revisions as necessary. In the end, a process is only as good as the person/team that develops it.
Technology is another area of importance. New tools for automation promise to have a sweeping impact on the scope and effectiveness of CDI. But once again, selecting the best tools to use, implementing them, addressing security concerns, and tracking efficacy all depend on having the right staff. Saddling your CDI program to the wrong kinds of technology only creates liabilities.
As a final consideration, think of how CDI affects the success or failure of all departments within a provider organization and how many stakeholders are involved. Making CDI a real priority depends on securing the buy-in of all these departments and stakeholders, and that takes a careful diplomatic touch. For complicated reasons, everyone from nurses, to doctors, to administrators can view CDI with either suspicion or outright derision. But if you have CDI staff that are strong communicators, effective educators, passionate advocates, and great listeners, it’s a lot easier to get everyone on board.
We chose to highlight the importance of people because CDI is often seen as a purely technical process. The thinking goes that if you have the right system in place it will be effective no matter who is behind it. But that kind of shortsighted thinking inevitably leads to documentation mistakes and institutional inefficiencies. And when you start getting contacted by payers, you will wish you had strong staff rather than a failed system to rely on. When you’re ready to enhance your CDI team with the best and brightest, contact MedPartners.