Question

After reading and reviewing the material you will design a CDI Program for a large 400 bed Medical Center with 40 hospital and ambulatory discharges.
Your design will address the following:
•What type of staffing will you have?
Will you have just clinical staff or just Health Information Management staff or will you have both? Please defend your reasoning.
•What type of organizational structure will you have?
Please include an organizational chart that describes the reporting relationships and shows the position responsible for the overall leadership of the CDI program
•Please include a job description for each position in your CDI program
•In your design please mention the benefits both clinical and financial of your CDI program

Answer 1

Here are six steps to implement an effective, long-lasting CDI program.

1. Analysis and interpretation. Before investing in CDI programs, hospitals should take time to analyze current clinical documentation, coding and revenue cycle performance. This can help hospital leaders target cash leakage, problematic quality reporting or insufficient clinical documentation.

2. Assemble a CDI team. Effective clinical documentation improvement programs employ a variety of specialists and staff members to influence meaningful change.

• CDI specialists. Hospital administrators should consider recruiting CDI specialists to lead documentation improvement teams. Successful CDI leaders typically have either nursing, pharmacy or health information management experience, possess working knowledge of state, federal and payer-specific requirements for coding, documentation and reporting and are CDI certified through the American Health Information Management Association.
  
• Physician champion. As creatures of habit, physicians often resist change to their traditional routines or workflows. Recruiting physician leaders for CDI programs can help facilitate inter-department communication and encourage adoption efforts among clinical staff. Effective physician champions are motivated to drive hospitalwide change and have a strong rapport among clinical staff.
  
• Cross-functional team. CDI leaders should assemble staff members from across all coding and documentation departments, including health information management, revenue cycle, clinical, administrative, case management and utilization review.

3. Choose a model. Different CDI models target different parts of a hospital's documentation life cycle. Hospitals can incorporate multiple models within their CDI initiatives depending on those areas that merit attention. Hospitals should develop and establish CDI programs that focus on health information management and coding, case management and continuity of care and quality reporting issues.

4. Choose a CDI tool. Hospitals can chose from a myriad of software platforms geared toward clinical documentation improvement, case management and computer-assisted coding to support CDI program efforts.

5. Establish employee training programs. CDI leaders and staff members should develop education programs to introduce hospital employees to best practices in documentation and coding. Physician training programs, for instance, should include mandatory CDI orientation for new clinical staff, encourage ICD-10 coding knowledge and share data on problematic diagnosis-related groups.

6. Record benchmarks to show return on investment. Sharing data on performance metrics with clinical, HIM and coding staff can help motivate employees to embrace change. By monitoring key performance trends, CDI leaders can also demonstrate the measurable value of CDI investment to hospital administrators. Helpful benchmarks to monitor include case mix index, number of days not final billed accounts, claims denials, targeted DRG rates and present on admission indicators.

Here are three reasons why implementing a CDI program can prove beneficial to your healthcare organization:

1) Quality reporting leading to accurate documentation

2) Achieving positive brand awareness

3) Minimizing room for medical error through improved communication