This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.
Have you ever spent hours working on a project, only to find out at a random meeting that another team has been working on the same project? This type of scenario can be frustrating to both teams and lead to distrust in the work process—not to mention wasted time that could have been spent collaborating or maximizing efficiency together—as the teams realize they have been working parallel to each other. With a good communication process in place, this all-too-frequent occurrence can be easily avoided.
Since the impact of high quality clinical documentation is now being identified beyond the appropriate DRG assignment and accurate case mix index (CMI), it is crucial for clinical documentation improvement (CDI) professionals to work with interdisciplinary teams. The teams to be included may vary by organization, but some of the teams commonly impacted by the work of CDI professionals include case management, quality, and core measures. When CDI collaborates with these other teams, the old silos that were once a norm in healthcare dissolve and communication pathways strengthen. Let’s take a closer look at some of the potential impacts.
The case management team focuses on the status of each patient admitted to the hospital to determine if they should be an inpatient or outpatient admission. In addition to this, they focus on insurance approvals, discharge planning, and any durable medical equipment (DME) that may be needed at home. The principal diagnosis may have an impact on deciphering if the hospital stay should be inpatient or outpatient. An example would be when a patient is admitted with only signs and symptoms and the order is written for inpatient status. It would be hard to support an inpatient admission without a diagnosis. CDI teams that assign working DRGs can also be a great benefit to case managers. When case managers have access to the geometric length of stay assigned they can better calculate a possible discharge time to assist in discharge planning.
Quality teams may review patient records that have patient safety indicators (PSI) or hospital-acquired conditions (HACs) assigned. To properly identify if a conditions is a PSI or HAC it is crucial that the accurate present on admission indicator is assigned. If a condition was present on admission, then it could not have occurred as a result of the hospital stay.
Core Measure Team
The core measure team monitors certain diagnoses to determine if the core measure set was met. Since the CDI team usually reviews records concurrently with a patient stay and assigns working ICD codes and DRGs, reports may be built from that data to allow the core measure team to identify opportunities concurrently as well.
Interdisciplinary team meetings may occur monthly or quarterly depending on the needs of the organization. During these meetings it is important that each team has an opportunity to discuss hot topics in their areas as well as current projects they are developing. Teams can learn beneficial information from each other and not only strengthen their own team, but strengthen their organization as a whole.
Does your CDI team have regular interdisciplinary team meetings? Do you see any benefits from these meetings in your organization? Have you had any struggles in setting up interdisciplinary team meetings?