Ways to Ensure Clinical Documentation Improvement (CDI) Success

November 15, 2019

Hospitals and ASCs across the nation are implementing clinical documentation improvement (CDI) programs. Focusing on maximizing revenue and reducing medical coding and billing errors, facilities are enforcing changes to improve end-to-end patient care.

The Benefits of Clinical Documentation Improvement

CDI programs can have multiple positive outcomes, including, but not limited to:

  • Standardizing care across teams
  • Reducing claim denials and increasing reimbursements
  • Managing procedure quality and bench-marking
  • Improving patient throughput and satisfaction
  • Developing more thorough, accurate procedure notes

Sites that utilize CDI programs are committed to providing the best patient care and improving overall revenue.

Clinical Documentation Improvement Planning

According to Becker’s Hospital Review, sites can take specific actionable steps to ensure CDI is successfully introduced to a care team.

1. Analyze current areas for improvement

Every site can have a different CDI plan. Some sites are great at maximizing patient throughput, but need to focus efforts on maintaining accurate coding. Some clinicians have standardized their procedure note documentation process but their nurses have trouble documenting procedure notes on busy days. Using expenses and revenue, determine areas where dollars are lost.

2. Designate CDI staff leaders

Choose leaders who are committed to developing a clinical documentation improvement plan. Because their jobs require significant coordination and planning, nurse and OR managers are generally great individuals to lead the way. In addition, physician-leaders can be extremely beneficial by helping other doctors adapt to change and improve buy-in.

3. Choose a model

CDI models allow for the improvement for different portions of the procedure documentation process. Once you’ve analyzed where your facility needs improvement, develop a program that targets these areas specifically.

4. Choose a CDI tool

CDI tools like procedure documentation software or nursing documentation solutions should help navigate your CDI initiative. Solutions that are developed to improve clinician workflow and increase procedure note accuracy are specifically designed for CDI programs. A report by Black Book in 2016 showed that nearly 90% of hospitals that outsourced clinical documentation functions made over 1.5 million in revenue reimbursement, according to EHR Intelligence.

5. Establish employee training programs

Informed employees are the best employees, so provide clinical staff with reasoning and timelines behind the CDI initiative. Give support where needed.

6. Show ROI and benchmark against targets

Interview staff and determine ways their day-to-day job can be improved for better site ROI. Choose tangible and intangible ways to show growth. Then, you have the ability to review your CDI progress as needed.

For more information regarding a tool for aiding clinical documentation improvement, see Provation Physician Documentation.

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